Just as the number of moms shooting heroin or popping prescription painkillers has surged in America, so too have the number of babies born dependent on these harmful drugs.
Neonatal abstinence syndrome, or NAS, is a massive problem for the U.S. health care system, one that’s costing north of $1.5 billion every year. Such babies suffer from symptoms like tremors, severe irritability, poor feeding, vomiting and diarrhea and must be carefully weaned off the drugs. Care for these infants can cost five times more than a normal newborn, according to some estimates.
With that in mind, the Institute for Healthcare Improvement hosted a web chat Thursday with several hospital execs aiming to share best practices for addressing NAS, and other negative downstream consequences of substance use during pregnancy. Kaiser Permanente, for one, has made a concerted effort to tackle this problem, dating back to another drug crisis — the 1980s crack epidemic.
The health system uses a four-principal approach, which involves screening every single pregnant woman for alcohol and drug use, placing a mental health provider in the obstetrics/gynecology department, and educating docs and women about the effects of drug abuse on their baby. Based on studies over years of time and working with nearly 50,000 women, Kaiser believes U.S. health care could save $2 billion using that same simple approach.
“Many people feel this is a hard patient population to work with and I would contend it’s not,” Nancy Goler, M.D., an ob/gyn and director of Kaiser’s Early Start Program, says. “You have to start somewhere, and these women want help. They want healthy babies, and we can make an enormous difference across the nation,” she adds.
The Oakland, Calif.-based provider deploys a no-frills, low-tech approach to addressing NAS. Goler, along with others in on the chat, stressed the importance of integrating mental-health services with a mom’s maternal care, so everything takes place in one visit, at one site. If a mother has to drive across town to see a substance-abuse expert after her prenatal care, she’s probably going to skip it.
Alongside integration, speakers emphasized the importance of eliminating stigma to help address NAS. Often, the knee-jerk reaction from a doc can be to chastise a mother for using drugs while pregnant, and rush to reach out to child services about taking the child away. But these women are grappling with a disease of the brain, and often have developed an addiction stemming from a long line of abuse and drug dependence, speakers said.
Pregnancy can be a powerful moment for hospital caregivers to intervene and put a mom back on the road to recovery, says Helen Bellanca, M.D., associate medical director of Health Share of Oregon, the largest coordinated care organization in the state. She notes that women who begin addiction treatment while expecting are three times more likely to be sober one year in than those who aren’t pregnant.
Health Share’s “Project Nurture” model places an emphasis on safety and transparency, and incorporates weekly group visits among addicted mothers, along with medication-assisted treatment and case management. Their approach utilizes three sites — a midwifery clinic, substance use treatment agency and family medicine clinic — and several organizations, all working in unison to treat these mothers.
“The idea is that the system can create an environment where we convey the message to them that it’s possible for them to parent in a safe and healthy way and that can be really deeply motivating and give women confidence to do the hard work of recovery,” Bellanca says.
Daisy Goodman, a nurse midwife with Dartmouth Hitchcock Medical Center, also stresses the importance of making a mom feel safe. They’ve even gone so far at the Lebanon, N.H., hospital of locating their treatment program 10 minutes away from the hospital campus in a private setting, and also have mothers share their substance use history anonymously through a tablet screen.
She believes that hospital leaders must take a regional, population-health based approach to addressing NAS, one that incorporates community treatment providers and state policymakers, among others. These are “extremely complex” patients to try to treat, but making progress is possible through integration and collaboration.
“This group of patients has suffered a great deal,” Goodman says. “All of our patients come from a multigenerational cycle of trauma and substance use in their families, and abuse and neglect is sort of what they grew up with. So, expecting them to be a very functional and capable parent right off is pretty unfair.
“It’s really our responsibility to treat the whole person and to think in terms of trauma awareness in the care we provide and really support them through a healing process,” she adds. “That’s what the work means to us.”