Medicated Assisted Treatment and Pregnancy:
An Anti-Stigma Interview with Adina Weissman
Interviewed by Nina Ovian
Welcome Adina and thank you for joining me today.
Could you please start by telling me about where you work and what you do there?
I’m the Care Coordination Manager at Jefferson Family Center, which is a women-only outpatient methadone clinic. The vast majority of our women are on methadone, but we also have a few women on subutex/suboxone, and a few women who are not on any medication-assisted treatment (MAT). We focus on pregnant and parenting women, so there is an added emphasis on parenting classes and the ways women need to balance engagement in treatment with parenting responsibilities.
We work with women who are pregnant and admitted to Jefferson hospital. While they are admitted they stabilize on either methadone or subutex– most of the time it's methadone. We do an intake and we get them placed in treatment, whether that's outpatient treatment, short-term inpatient, or a long-term residential program, and we will place them while they are still in the hospital.
We also work with all of the women at the clinic itself in terms of doing check-ins, figuring out if there are any barriers to engagement or treatment, helping with struggles, and just trying to keep them engaged in treatment and maintain sobriety.
There is so much misinformation and stigma surrounding pregnancy and substance use. Can you speak to some of these misconceptions around MAT and what is considered safe during pregnancy and breastfeeding?
It is definitely really difficult that women face a lot of shame and guilt for using illicit substances or even being on MAT while they are pregnant. They face both stigma that they have internalized and also from the other people in their lives.
It is safe to be on Methadone while pregnant. It is safe to be on Methadone while breastfeeding. Studies have shown that the amount of Methadone that passes through the milk to the baby is pretty miniscule and that if the woman chooses to breastfeed, the benefits of breastmilk far outweigh that small amount of methadone that gets transmitted. The benefits of Methadone and being engaged in the clinic far outweigh these potential negative things that could come up because of it.
Part of the problem is that when women are using methadone or any MAT while they are pregnant, there is a chance that the baby will still go through Neonatal Abstinence Syndrome (NAS) after birth, meaning that basically the baby goes through withdrawal when they're born. Babies that are born with NAS at Jefferson will stay for five days to be monitored for withdrawal symptoms and if they do score high enough on those scales they will start with Buphrenophine, then get titrated up. If they are still having withdrawal symptoms they will add another medication and titrate up until the baby is comfortable, then l wean the baby off all the medications slowly and safely after which the baby would be ready to be discharged.
So the idea that a woman would think that “okay, I'm doing the right thing, I'm getting on methadone, I’m gonna get engaged in treatment but my baby still might go through withdrawal” is tough. That is a very real risk and doctors don't really know what would lead a baby to be more or less likely to go through withdrawal. It can be difficult for women to face that and think “I did this to my baby, I’m the reason they are going through withdrawal.”
Something we like to tell all of our moms is that it is safer for them and for the baby for them to be on Methadone or Subutex than to be using illicit substances during pregnancy. When you are on MAT, it is a prescribed dose and there are typically less opiates in your system because the goal is not to get high or to oversedate, but just to manage those withdrawal systems. If you are using Heroin or Fentanyl you tend to use more because the goal is often to get high. There are also all of the lifestyle decisions going on when someone is using illicit substances versus when they are engaged in the clinic—for example, they know where they are getting their Methadone and they don't need to worry or do whatever they need to do in order to buy illicit substances. So yes, there is a risk, but it is still the better option.
Another thing women struggle with, at least in Philadelphia but I am sure it is similar in other places, if a woman has a positive urine for illicit substances during pregnancy and the hospital knows about it, after delivery the social worker in the hospital makes a call to the Department of Human Services (DHS) to make a child labor report. So women sometimes feel stuck because they are going to the hospital for treatment but now it's going to bite them in the butt afterwards, because getting into treatment is why there is now a DHS case against them. That can be really difficult for women feeling like they are going to get punished for trying to go into treatment.
We try to address it but it's also important to understand there are no detoxes that will take a pregnant woman because of the risk of putting the baby in distress, even a risk of miscarriage, especially early in the pregnancy. So they can’t go to a facility to detox off of any opioids. The only other options left are to go into the hospital and get stabilized on MAT or attempt to do it themselves with the idea that if they can detox themselves (and forgo prenatal care) but when they go to deliver and there’s nothing in their system, then there is no reason for DHS to get called.
We try to support people but also walk them through this idea that detoxing themselves is difficult and dangerous, including leading to miscarriage. By detoxing you are putting the baby in distress and there is no guarantee that you will be successful. And just because a DHS report is open does not mean that they are not going to get custody of the baby when the baby is ready to be discharged.
I know you mentioned fear of the criminal justice system, but what are some of the other major barriers to care that pregnant people who use substances are facing?
A big barrier to engagement is often transportation. Depending on where they are coming from in the city, it can be very time consuming to take public transportation to get to the clinic, or they don't have the money. There are services in place for people who are on medicaid insurance to get free transportation for medical appointments ( coming to a methadone clinic is considered a medical appointment because it is a prescribed substance). So women on medicaid who are coming daily are able to get a monthly transpass which is really helpful. However, things can happen– they stop working because they're fragile, they lose it, , or they might be selling it.
Another issue is that you need a photo ID to pick the transpass up every month and that can be a barrier. Gathering all the documents to get a photo ID can be difficult or the costs can be prohibitive for some people because many of our women are not working. Some women get cash assistance but for some women their only means of support are food stamps.
There is also overall financial stress that isn't necessarily specific to them being on Methadone, but it often goes hand in hand with being low income and all the general stressors and barriers that come along with that. Affordable housing is something that many of our women struggle with. Subsidized housing is not always great and they may be trying to move or they don't feel safe in that area, or there may be a lot of drug use in that area, which is not supportive of their recovery.
What is something that surprised you when you started working with this population?
Before I started working I had a certain idea of DHS and what situation would lead to a child being removed from the home or a baby not being discharged to mom after they’re stable to go home from the hospital. It was sort of in my mind, not that the women deserved it, but there is a genuine reason that this is what's best for the baby or best for the child to not be with mom.
Right from the beginning it was very eye-opening to see that's not always the case! Unfortunately, in our experience DHS workers have a lot of leeway with their decisions. There's not one standard that someone would have to meet and either you meet it and this happens or they don't meet it and something else happens. We have had women in very similar situations, that have two very different outcomes with DHS, purely because this specific DHS worker had a different opinion or made a different decision. I have seen so many women trying so hard for reunification or having been stable in their recovery for five months but the DHS worker is saying no that's not enough time, whereas someone else has been stable for two months or consistently testing positive but does get custody of the baby.
Just seeing how hard so many women fight to regain custody and meet the criteria and expectations set by DHS workers and judges and lawyers and all these people who have so much power over them and their lives, has been really important for me to see and to have that view of the other side. Now, many times, I will disagree with a DHS worker's decision but then I still need to support our women, and not have that decision become a destabilizing force in their lives, I help them continue to try and move forward and maintain their recovery while they're struggling with this, as it's so easy for people to lose hope or faith and think “I don’t have my baby, so what's the point?”
I think that is one of the biggest things I have learned, is how many women try so hard, but the system is not always set up to see them succeed in the way that I thought that it was and would hope that it would be.
Why is it so important for these specialized services to exist, as opposed to putting pregnant people into general methadone clinics and services?
We are the only women-only program in the city in terms of outpatient treatment, and I have heard from so many women that they wanted to come to the Family Center, even with various logistical barriers, because of the fact that we are female only. We have so many women that have trauma histories, often sexual trauma, whether that was while they were under the influence or what led them to start using. Often they feel safer in a community that is all women, where they’re not retraumatized by various interactions and seeing men on such a regular basis while they’re in such a vulnerable place. When you're in treatment you're in groups, sharing a lot of really personal things, and a lot of women feel supported when they are sharing these things in a room that is exclusively women.
How has COVID-19 affected patient care?
I don’t think it's affecting pregnant women more than other women or anyone else in recovery, but it has made things so much more difficult. All of our services have moved to being virtual and so when women come in, they get medication and they leave.
Sometimes we have short check-ins face-to- face, but as waves of COVID have crested, we’ve even had to cut back on those throughout these last few years. Virtual is difficult in that our women don't always have stable phone numbers or have access to the internet to be able to join groups on zoom. Sessions are a little bit easier just being on the phone, but even having enough minutes or the privacy at home has been a big barrier. The support is just different when it's virtual versus in person, and being able to truly sit with someone while they’re with their emotions is just so different from supporting them over the phone.
Along with getting less support from the clinic, many can't get out and interact with their other supports as much, so there are more stressors, especially for women who have kids that are school aged. It makes it really difficult for a lot of people’s recovery.
Before we go, is there any last thing you would like the general public to know?
I would say please don’t judge these women. They got into treatment because they want to improve, they want to get sober, and they want something for their life and their child's life. No woman is actively harming herself or her baby, and everyone is just making the best decisions that they can. Getting on MAT is their way of doing it, and people should be supported and applauded for that rather than being made to feel inferior or shamed for the fact that they were using while pregnant.
That was so beautifully said. Thank you so much for taking the time to speak with me today and sharing such important information.