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STATEMENT ON DRUG USE IN PREGNANCY: AN URGENT PROBLEM FOR NEW YORK CITY* COMMITTEE ON PUBLIC HEALTH The New York Academy of Medicine New York, New York T HE HEALTH EFFECTS OF DRUG AND ALCOHOL abuse have been exten-
sively documented. 1 Among the adverse consequences are specific ones for pregnant women and their offspring. The association between multiple sexual partners and illicit drug use is further associated with Acquired Immune Deficiency Syndrome and leads to increased numbers of sexually transmitted diseases and their sequelae such as pelvic inflammatory disease, ectopic pregnancy, and perhaps preterm delivery.2,3 In Kings County Hospital in Brooklyn, New York, there has been a greater than 300% increase in the incidence of positive syphilis serology in cord bloods of babies born in the hospital between 1985 and 1988.4 Drug exposed infants are seven times as likely as the unexposed to be infected by syphilis and seven times as likely to be exposed to human immunodeficiency virus (HIV).5 They are three times as likely to be of low birth weight than the unexposed, more than twice as likely to die in the first year of life, more likely to have smaller head circumference, and to exhibit a variety of "soft" behavioral/neurological signs that make them harder to care for and may presage future developmental delay.6-8 In New York City the associated AIDS and sexually transmitted diseases epidemics make the drug problem an especially urgent one. ESTIMATES OF NUMBERS OF WOMEN USING DRUGS DURING PREGNANCY IN NEW YORK CITY
The number of birth certificates indicating maternal substance use has tripled in New York City from 730 in 1981 (6.7/1000 livebirths) to 2586 (20.3/1000 livebirths) in 1987.6 The number of certificates noting heroin use increased from 206 in 1978 to 361 in 1986 and those noting cocaine increased from 68 in 1978 to 1364 in 1986. Currently, cocaine is listed on 66% of those *Prepared by the Subcommittee on Maternity and Family Planning Services and approved by the Committee on Public Health of the New York Academy of Medicine October 2, 1989. Approved by the Council of the New York Academy of Medicine October 11, 1989.
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certificates noting maternal substance use.6 These data clearly underscore the problem. One hospital based anonymous urine toxicology survey of neonates 1985-86 indicated 11% were positive for illicit drugs.9 Another such survey of women in labor in 1988 yielded 13.1% positive for cocaine with an additional 1.4% positive for opiates (N = 1300). 10 A similar survey in 1987 (N = 200) found 20% positive for cocaine. I I Data from the municipal hospital system indicated drug related diagnoses in 5% of births in 1987.12 CURRENT SOCIAL CONSEQUENCES
Children born to substance-abusing mothers are often placed in foster care. However, because of the increasing numbers of such cases and the shortage of foster homes, these babies are boarded in hospitals or congregate care facilities. In 1987, when the boarder baby situation was called a "crisis" in New York City, maternal substance use was the primary reason for boarder baby status, accounting for 40% of 300 + cases. Approximately one third of these drug-exposed infants were ultimately discharged to the biological family after boarding in hospitals an average of 50-60 days. 13 A recent report by the Comptroller of New York City indicated that maternal drug use (48%) and inadequate housing (49%) were the two primary reasons for boarder status, and that there are approximately 300 children under two years of age boarding in hospitals and another 130 in congregate care on any given day. 14 NEW YORK CITY DRUG TREATMENT AND FAMILY REUNIFICATION
Although the New York State Child Welfare Reform Act of 1979 mandates that preventive services be provided to families at risk of having children placed in foster care, drug treatment is not specified to be such a preventive service. 15 The Division of Substance Abuse Services estimates that in New York State only 20% of pregnant narcotic users and 7% of pregnant cocaine users are in drug treatment. 16 San Francisco is piloting an interagency collaborative effort to plan preventively together with pregnant addicts so that these pregnant women can maintain custody and receive the supportive services necessary after the birth of their children. 17 In contrast, Special Services for Children does not routinely attempt to enroll mothers in drug treatment to prevent foster care placement. In fact, according to a recent survey'8 half of the drug treatment programs in the city refuse to accept pregnant women; only one-third will treat pregnant women on Medicaid and only 13% provide detoxification from crack for pregnant women on Medicaid. Thus, the overall shortage of drug treatment slots in New York City is compounded for pregnant women who are frequently excluded. Bull. N.Y. Acad. Med.
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Furthermore, the paucity of promising modalities for the treatment of crack addiction is complicated by uncertainty about optimal medical management during pregnancy. There has been controversy about the use of methadone for detoxification or maintenance during pregnancy, as well as about optimal dosage schedule at different gestational states. 19-25 Treatment modalities such as psychotherapy, acupuncture, and other medications have not been rigorously evaluated in pregnancy. Preliminary data from one New York City hospital based acupuncture program that treats pregnant women suggests rates of retention in the program and clean urines that compare favorably to retention and clean urine rates published from other drug treatment programs.26 A handful of programs around the country that bring together obstetric, pediatric, drug treatment, medical and parenting training services under one roof in order to provide comprehensive care to pregnant and parenting addicts and their children report that this is the most promising approach. 27,28 This contrasts with findings of national surveys conducted by the National Institute for Drug Abuse which indicated that drug treatment program staff were often hostile to women and did not address their educational, gynecologic or parenting needs, and that many of those drug treatment programs specifically geared to women did not provide contraceptive or gynecologic care.29,30 Two other surveys indicate that obstetricians have often been reluctant to deal with addicted pregnant patients.3 1,32 The recent survey in New York City previously cited indicated that fewer than half of those drug treatment programs accepting pregnant women directly provided or arranged for prenatal care. Only two made provisions for clients' children.18 Since wanted pregnancy appears to be a time when addicted women can be highly motivated to enter treatment, and since the medical and social consequences for the women and children are so severe, we would recommend that: 1. Experienced and committed experts be convened to explore new approaches for the treatment of substance abuse during pregnancy and that these approaches be subjected to rigorously designed clinical trials. No treatment modality employed to date represents a "magic bullet" cure for addiction. Drug treatment, obstetric and pediatric care should be coordinated. 2. Treatment modalities that appear promising be made widely available through the expansion of treatment slots; a media campaign to publicize the availability of services; and a means to expedite access, such as incorporation into the appointment system of the Pregnancy Healthline Vol. 66, No. 2, March-April 1990
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of the New York City Department of Health. Short-term costs will be offset by long term savings achieved by reducing the numbers of neonates requiring intensive care and foster placement. 3. The New York State Child Welfare Reform Act of 1979 be amended to stipulate that drug treatment be specified as a preventive service mandatorily offered to families at risk of losing custody of children because of parental drug use and that local social service agencies be required to provide ancillary services to make active participation in treatment programs feasible (e.g., child care). 4. Parenting training/early childhood stimulation centers be established for parents whose children are placed in foster care at birth. This would encourage the development of parent-child relationships that could make the goal of family reunification feasible. The minimum visitation between parent and child in foster care be increased from the present period of two hours biweekly in order to promote the maternal-infant relationship.33 REFERENCES 1. National Institute on Drug Abuse: Research Monograph Series 1-77, DHHS U.S., Washington D.C., Govt. Print. Off., 1975-1988. 2. Joachim, G., Nadler, J.L., Goldberg, M., et al.: Relationship of syphilis to drug use and prostitution, Connecticut and Philadelphia, Pennsylvania. MMWR 37:755-64, 1988. 3. CDC: Syphilis and congenital syphilisUnited States 1985-1988. MMWR 37:486-89, 1988. 4. Minkoff, H.: Personal Communication, 1989. 5. Minkoff, H.: Proceedings of the International AIDS meeting. Montreal, Canada, 1989. 6. Habel, L., Kaye, K., Lee, J., and Grossi, M.T.: Trends in Reporting of Maternal Substance Abuse in New York City 1978-1987. American Public Health Association annual meeting, Boston. November 14, 1988. 7. Finnegan, L.P.: The effects of narcotics and alcohol on pregnancy and the newborn. Ann. N. Y. Acad. Sci. 363:136-57, 1981. 8. Chasnoff, I.J., Burrows, W.J., Schnoll, S.M., and Burors, K.A.: Cocaine use in
9. 10.
11.
12.
13.
14.
15.
pregnancy. N. Engl. J. Med. 313:666-69, 1985. Bateman, D. Hospital. Personal communication, 1988. Valencia, G., McCalla, S., da Silva, M., et al.: Epidemiology of cocaine use during pregnancy at Kings County Hospital Center. American Pediatric Society/Society for Pediatric Research, 1989. Parente, J.: Substance Abuse During Pregnancy. New York State Medical Society Annual Meeting. New York, April 1988. Selected Characteristics of Livebirths. HHC Maternity Sites, New York City, 1987. Office of Women's Health, Health and Hospitals Corporation, New York. Driver, C., Chavkin, W., and Higginson, G.: Survey of infants awaiting placement in voluntary hospitals 198687. New York, Department of Health, 1987. Office of Policy Management, Office of the Comptroller, City of New York: Whatever Happened to the Boarder Babies? New York, 1989. The Temporary State Commission on Child Welfare: The Children of the State Bull. N.Y. Acad. Med.
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weight. Pediatrics 58:681-85, 1976. III. New York and Albany, March 1980. 16. Deren, S., Frank, B., and Schmeider, J.: 26. Smith, M.O.: Accupuncture as a Treatment for Drug Dependent Mothers. New Children of Substance Abusers in New York City Council Subcommittees on York State: Trends and Estimates. TreatMedical Technology, April 11, 1988. ment Issue Report No. 67. New York State Division of Substance Abuse Ser- 27. Suffet, F. and Brotman, R.: A comprehensive care program for pregnant advices, 1988. dicts: Obstetrical, neonatal and child 17. Dr. Geraldine Oliva, San Francisco Dedevelopment outcomes. J. Add. partment of Health. Personal Communi19:199-219, 1984. cation, 1988. 18. Chavkin, W.: Drug treatment during 28. Finnegan, L.P., editor: Drug Dependence in Pregnancy: Clinical Managepregnancy-Report of a survey. Submitment of Mother and Child. National ted for publication. Institute on Drug Abuse, Service Re19. Zuspan, F.P., Gumpell, J.A., Mejiasearch Branch, Rockville, MD. WashZelaya, A., et al.: Fetal stress from ington, D.C., Govt. Print. Off., 1978. methadone withdrawal. Am. J. Obstet. 29. Beschner, G.M. and Thompson, Gynecol.:122-43, 1975. 20. Rajegowda, B.K., Glass, L., Evans, P.: Women and Drug Abuse Treatment: Needs and Services. Rockville MD, NaH.E., et al.: Methadone withdrawal in tional Institute on Drug Abuse 198 newborn infants. J. Pediatr. 81:532-34, 1972. DHHS Pub No (ADM) 84-1057, 1981. 21. Ostrea, E.M., Chavez, C.J., and Services Research Monograph Series. Strauss, M.E.: A study of factors that 30. Reed, B. and Moise, R.: Implications influence the severity of neonatal narfor Treatment and Future Research in cotic withdrawal. J. Pediatr. 88:642-45, Addicted Women: Family Dynamics, 1976. Self Perception, and Support System. 22. Madden, J.D., Chappel, J.N., Zuspan, National Institute on Drug Abuse, F.P., et al.: Observation and treatment DHEW Pub No (ADM) 80-762. Washof neonatal narcotic withdrawal. Am. J. ington, D.C., Govt. Print. Off., 1979, Obstet. Gynecol. 127:199-201. pp. 114-30. 23. Blinick, G., Intrussi, C.E., Jerez, E., et 31. Ryan, V.S.: Hospital Treatment of al.: Methadone assay in pregnant women Pregnant Addicts. Detroit, National and progeny. Am. J. Obstet. Gynecol. Women's Drug Research Coordinating 121:617-21, 1975. Project. 1977. 24. Stimmel, B., Goldberg, J., Reisman, 32. Driver, S., Chavkin, W., Breitbart, W., A., et al.: Fetal outcome in narcotic et al.: Broadening the vision: Profiles in dependent women: The importance of reproductive health care program. New the type of maternal narcotic used. York City Department of Health and Am. J. Drug Alcohol Abuse 9:282-95, Medical Health Research Assoc., 1988. 1982-83. Ford Grant 875-1028. 25. Kandall, S.R., Albin, S., Lewison, J., 33. 18 New York Code of Rules and Regulaet al.: Differential effects of maternal tions 430:12(d)(1)(i) heroin and methadone use on birth-
Vol. 66, No. 2, March-April 1990
STATEMENT ON DRUG USE IN PREGNANCY: AN URGENT PROBLEM FOR NEW YORK CITY* COMMITTEE ON PUBLIC HEALTH The New York Academy of Medicine New York, New York T HE HEALTH EFFECTS OF DRUG AND ALCOHOL abuse have been exten-
sively documented. 1 Among the adverse consequences are specific ones for pregnant women and their offspring. The association between multiple sexual partners and illicit drug use is further associated with Acquired Immune Deficiency Syndrome and leads to increased numbers of sexually transmitted diseases and their sequelae such as pelvic inflammatory disease, ectopic pregnancy, and perhaps preterm delivery.2,3 In Kings County Hospital in Brooklyn, New York, there has been a greater than 300% increase in the incidence of positive syphilis serology in cord bloods of babies born in the hospital between 1985 and 1988.4 Drug exposed infants are seven times as likely as the unexposed to be infected by syphilis and seven times as likely to be exposed to human immunodeficiency virus (HIV).5 They are three times as likely to be of low birth weight than the unexposed, more than twice as likely to die in the first year of life, more likely to have smaller head circumference, and to exhibit a variety of "soft" behavioral/neurological signs that make them harder to care for and may presage future developmental delay.6-8 In New York City the associated AIDS and sexually transmitted diseases epidemics make the drug problem an especially urgent one. ESTIMATES OF NUMBERS OF WOMEN USING DRUGS DURING PREGNANCY IN NEW YORK CITY
The number of birth certificates indicating maternal substance use has tripled in New York City from 730 in 1981 (6.7/1000 livebirths) to 2586 (20.3/1000 livebirths) in 1987.6 The number of certificates noting heroin use increased from 206 in 1978 to 361 in 1986 and those noting cocaine increased from 68 in 1978 to 1364 in 1986. Currently, cocaine is listed on 66% of those *Prepared by the Subcommittee on Maternity and Family Planning Services and approved by the Committee on Public Health of the New York Academy of Medicine October 2, 1989. Approved by the Council of the New York Academy of Medicine October 11, 1989.
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certificates noting maternal substance use.6 These data clearly underscore the problem. One hospital based anonymous urine toxicology survey of neonates 1985-86 indicated 11% were positive for illicit drugs.9 Another such survey of women in labor in 1988 yielded 13.1% positive for cocaine with an additional 1.4% positive for opiates (N = 1300). 10 A similar survey in 1987 (N = 200) found 20% positive for cocaine. I I Data from the municipal hospital system indicated drug related diagnoses in 5% of births in 1987.12 CURRENT SOCIAL CONSEQUENCES
Children born to substance-abusing mothers are often placed in foster care. However, because of the increasing numbers of such cases and the shortage of foster homes, these babies are boarded in hospitals or congregate care facilities. In 1987, when the boarder baby situation was called a "crisis" in New York City, maternal substance use was the primary reason for boarder baby status, accounting for 40% of 300 + cases. Approximately one third of these drug-exposed infants were ultimately discharged to the biological family after boarding in hospitals an average of 50-60 days. 13 A recent report by the Comptroller of New York City indicated that maternal drug use (48%) and inadequate housing (49%) were the two primary reasons for boarder status, and that there are approximately 300 children under two years of age boarding in hospitals and another 130 in congregate care on any given day. 14 NEW YORK CITY DRUG TREATMENT AND FAMILY REUNIFICATION
Although the New York State Child Welfare Reform Act of 1979 mandates that preventive services be provided to families at risk of having children placed in foster care, drug treatment is not specified to be such a preventive service. 15 The Division of Substance Abuse Services estimates that in New York State only 20% of pregnant narcotic users and 7% of pregnant cocaine users are in drug treatment. 16 San Francisco is piloting an interagency collaborative effort to plan preventively together with pregnant addicts so that these pregnant women can maintain custody and receive the supportive services necessary after the birth of their children. 17 In contrast, Special Services for Children does not routinely attempt to enroll mothers in drug treatment to prevent foster care placement. In fact, according to a recent survey'8 half of the drug treatment programs in the city refuse to accept pregnant women; only one-third will treat pregnant women on Medicaid and only 13% provide detoxification from crack for pregnant women on Medicaid. Thus, the overall shortage of drug treatment slots in New York City is compounded for pregnant women who are frequently excluded. Bull. N.Y. Acad. Med.
DRUG DRUG USE USE
195 195
Furthermore, the paucity of promising modalities for the treatment of crack addiction is complicated by uncertainty about optimal medical management during pregnancy. There has been controversy about the use of methadone for detoxification or maintenance during pregnancy, as well as about optimal dosage schedule at different gestational states. 19-25 Treatment modalities such as psychotherapy, acupuncture, and other medications have not been rigorously evaluated in pregnancy. Preliminary data from one New York City hospital based acupuncture program that treats pregnant women suggests rates of retention in the program and clean urines that compare favorably to retention and clean urine rates published from other drug treatment programs.26 A handful of programs around the country that bring together obstetric, pediatric, drug treatment, medical and parenting training services under one roof in order to provide comprehensive care to pregnant and parenting addicts and their children report that this is the most promising approach. 27,28 This contrasts with findings of national surveys conducted by the National Institute for Drug Abuse which indicated that drug treatment program staff were often hostile to women and did not address their educational, gynecologic or parenting needs, and that many of those drug treatment programs specifically geared to women did not provide contraceptive or gynecologic care.29,30 Two other surveys indicate that obstetricians have often been reluctant to deal with addicted pregnant patients.3 1,32 The recent survey in New York City previously cited indicated that fewer than half of those drug treatment programs accepting pregnant women directly provided or arranged for prenatal care. Only two made provisions for clients' children.18 Since wanted pregnancy appears to be a time when addicted women can be highly motivated to enter treatment, and since the medical and social consequences for the women and children are so severe, we would recommend that: 1. Experienced and committed experts be convened to explore new approaches for the treatment of substance abuse during pregnancy and that these approaches be subjected to rigorously designed clinical trials. No treatment modality employed to date represents a "magic bullet" cure for addiction. Drug treatment, obstetric and pediatric care should be coordinated. 2. Treatment modalities that appear promising be made widely available through the expansion of treatment slots; a media campaign to publicize the availability of services; and a means to expedite access, such as incorporation into the appointment system of the Pregnancy Healthline Vol. 66, No. 2, March-April 1990
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of the New York City Department of Health. Short-term costs will be offset by long term savings achieved by reducing the numbers of neonates requiring intensive care and foster placement. 3. The New York State Child Welfare Reform Act of 1979 be amended to stipulate that drug treatment be specified as a preventive service mandatorily offered to families at risk of losing custody of children because of parental drug use and that local social service agencies be required to provide ancillary services to make active participation in treatment programs feasible (e.g., child care). 4. Parenting training/early childhood stimulation centers be established for parents whose children are placed in foster care at birth. This would encourage the development of parent-child relationships that could make the goal of family reunification feasible. The minimum visitation between parent and child in foster care be increased from the present period of two hours biweekly in order to promote the maternal-infant relationship.33 REFERENCES 1. National Institute on Drug Abuse: Research Monograph Series 1-77, DHHS U.S., Washington D.C., Govt. Print. Off., 1975-1988. 2. Joachim, G., Nadler, J.L., Goldberg, M., et al.: Relationship of syphilis to drug use and prostitution, Connecticut and Philadelphia, Pennsylvania. MMWR 37:755-64, 1988. 3. CDC: Syphilis and congenital syphilisUnited States 1985-1988. MMWR 37:486-89, 1988. 4. Minkoff, H.: Personal Communication, 1989. 5. Minkoff, H.: Proceedings of the International AIDS meeting. Montreal, Canada, 1989. 6. Habel, L., Kaye, K., Lee, J., and Grossi, M.T.: Trends in Reporting of Maternal Substance Abuse in New York City 1978-1987. American Public Health Association annual meeting, Boston. November 14, 1988. 7. Finnegan, L.P.: The effects of narcotics and alcohol on pregnancy and the newborn. Ann. N. Y. Acad. Sci. 363:136-57, 1981. 8. Chasnoff, I.J., Burrows, W.J., Schnoll, S.M., and Burors, K.A.: Cocaine use in
9. 10.
11.
12.
13.
14.
15.
pregnancy. N. Engl. J. Med. 313:666-69, 1985. Bateman, D. Hospital. Personal communication, 1988. Valencia, G., McCalla, S., da Silva, M., et al.: Epidemiology of cocaine use during pregnancy at Kings County Hospital Center. American Pediatric Society/Society for Pediatric Research, 1989. Parente, J.: Substance Abuse During Pregnancy. New York State Medical Society Annual Meeting. New York, April 1988. Selected Characteristics of Livebirths. HHC Maternity Sites, New York City, 1987. Office of Women's Health, Health and Hospitals Corporation, New York. Driver, C., Chavkin, W., and Higginson, G.: Survey of infants awaiting placement in voluntary hospitals 198687. New York, Department of Health, 1987. Office of Policy Management, Office of the Comptroller, City of New York: Whatever Happened to the Boarder Babies? New York, 1989. The Temporary State Commission on Child Welfare: The Children of the State Bull. N.Y. Acad. Med.
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weight. Pediatrics 58:681-85, 1976. III. New York and Albany, March 1980. 16. Deren, S., Frank, B., and Schmeider, J.: 26. Smith, M.O.: Accupuncture as a Treatment for Drug Dependent Mothers. New Children of Substance Abusers in New York City Council Subcommittees on York State: Trends and Estimates. TreatMedical Technology, April 11, 1988. ment Issue Report No. 67. New York State Division of Substance Abuse Ser- 27. Suffet, F. and Brotman, R.: A comprehensive care program for pregnant advices, 1988. dicts: Obstetrical, neonatal and child 17. Dr. Geraldine Oliva, San Francisco Dedevelopment outcomes. J. Add. partment of Health. Personal Communi19:199-219, 1984. cation, 1988. 18. Chavkin, W.: Drug treatment during 28. Finnegan, L.P., editor: Drug Dependence in Pregnancy: Clinical Managepregnancy-Report of a survey. Submitment of Mother and Child. National ted for publication. Institute on Drug Abuse, Service Re19. Zuspan, F.P., Gumpell, J.A., Mejiasearch Branch, Rockville, MD. WashZelaya, A., et al.: Fetal stress from ington, D.C., Govt. Print. Off., 1978. methadone withdrawal. Am. J. Obstet. 29. Beschner, G.M. and Thompson, Gynecol.:122-43, 1975. 20. Rajegowda, B.K., Glass, L., Evans, P.: Women and Drug Abuse Treatment: Needs and Services. Rockville MD, NaH.E., et al.: Methadone withdrawal in tional Institute on Drug Abuse 198 newborn infants. J. Pediatr. 81:532-34, 1972. DHHS Pub No (ADM) 84-1057, 1981. 21. Ostrea, E.M., Chavez, C.J., and Services Research Monograph Series. Strauss, M.E.: A study of factors that 30. Reed, B. and Moise, R.: Implications influence the severity of neonatal narfor Treatment and Future Research in cotic withdrawal. J. Pediatr. 88:642-45, Addicted Women: Family Dynamics, 1976. Self Perception, and Support System. 22. Madden, J.D., Chappel, J.N., Zuspan, National Institute on Drug Abuse, F.P., et al.: Observation and treatment DHEW Pub No (ADM) 80-762. Washof neonatal narcotic withdrawal. Am. J. ington, D.C., Govt. Print. Off., 1979, Obstet. Gynecol. 127:199-201. pp. 114-30. 23. Blinick, G., Intrussi, C.E., Jerez, E., et 31. Ryan, V.S.: Hospital Treatment of al.: Methadone assay in pregnant women Pregnant Addicts. Detroit, National and progeny. Am. J. Obstet. Gynecol. Women's Drug Research Coordinating 121:617-21, 1975. Project. 1977. 24. Stimmel, B., Goldberg, J., Reisman, 32. Driver, S., Chavkin, W., Breitbart, W., A., et al.: Fetal outcome in narcotic et al.: Broadening the vision: Profiles in dependent women: The importance of reproductive health care program. New the type of maternal narcotic used. York City Department of Health and Am. J. Drug Alcohol Abuse 9:282-95, Medical Health Research Assoc., 1988. 1982-83. Ford Grant 875-1028. 25. Kandall, S.R., Albin, S., Lewison, J., 33. 18 New York Code of Rules and Regulaet al.: Differential effects of maternal tions 430:12(d)(1)(i) heroin and methadone use on birth-
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