CATR: How big of a problem is addiction in pregnancy?

Dr. Johnson: A 2020 Substance Abuse and Mental Health Services Administration (SAMHSA) survey showed that about one in 10 pregnant people reported using cannabis, nicotine, alcohol, stimulants, or illicit opioids within the previous month (www.tinyurl.com/yc6x4vcp). The overall pattern mimicked that of the general population, though with an overall lower prevalence, with cannabis and nicotine being the most common, followed by alcohol and other illicit substances.

CATR: Many pregnant patients who use substances worry about Child Protective Services (CPS) getting involved. How does CPS get alerted in the first place?

Dr. Johnson: To start, it’s useful to understand the Child Abuse Prevention and Treatment Act (CAPTA). First passed in the 1970s, ­CAPTA was meant to protect minors from abuse, which it defines broadly. It includes physical, emotional, and sexual abuse; exploitation; and anything that puts a child at “imminent risk of serious harm.” The CAPTA Family Care Plan is a later addition focused on substance use. It requires CPS to be notified of all babies prenatally exposed to alcohol or other drugs.

CATR: And how is that reported?

Dr. Johnson: Well, it’s not necessarily a report. The law requires that CPS get a “notification,” which is simply informing them about the results of a toxicology screen. The term “report” is reserved for when you have more specific reasons to be concerned—the child is not safe, intentional harm, that sort of thing.

CATR: What are the mechanics of filing a notification? Are providers legally obligated to file the notifications themselves?

Dr. Johnson: As with so many legal questions, the answer is “it depends.” CAPTA is federal legislation, but each state and county will have its own interpretation. The good news is that hospitals tend to have a set protocol. While the protocols might differ in their fine details, the broad strokes are similar across clinical ­settings.

CATR: Could you explain the protocol that your health care system follows, just to provide an illustrative example?

Dr. Johnson: In our hospital, policy requires a urine drug screen (UDS) on babies born to mothers with a history of a substance use disorder (SUD). If we detect anything unexpected, legally we have to notify CPS. We let the parents know about the notification. Most states have an online portal or a phone number to call.

CATR: And then what happens?

Dr. Johnson: Again, it depends. If the baby tests positive for a substance such as methamphetamine, cocaine, or opioids, CPS will usually do an investigation that includes a home visit and an interview with the family. The case usually stays open for 30–45 days. If CPS determines that the newborn has what they need and the environment is safe, the case will be closed.

CATR: What are the possible outcomes of these investigations?

Dr. Johnson: Resources might be recommended to the family, or CPS might continue to follow the case for a time. Parents can be connected to SUD treatment. Things can get more complicated when there are multiple children in the house or if there’s been prior CPS involvement. But regardless of the outcome, it’s important to acknowledge that these investigations can be intrusive and very stressful for families.

CATR: Can the baby be separated from the parents by CPS?

Dr. Johnson: Yes. In my hospital system, it is not common for CPS to prevent the baby going home with the family. When that does happen, it is almost always because there are other serious concerns—maybe prior CPS involvement, a history of domestic violence, or a history of child abuse. It’s possible that a baby gets removed from the house because of that investigation we were discussing. If CPS determines that the home environment is unsafe, they have the authority to remove the child. This is usually not done solely based on a positive UDS, but because of other issues.

CATR: We’ve heard horror stories of babies getting taken away because a parent is on a medication for opioid use disorder (www.tinyurl.com/87f7zx6k). I imagine these types of stories might make patients hesitant to seek treatment.

Dr. Johnson: Yes, we’ve all read about these cases. Unfortunately, the multiple layers of legal interpretations can lead to some pretty extreme, and terrible, outliers. The risk of a bad outcome because of untreated opioid use disorder vastly outweighs the very small risk of something like this happening. In fact, opioid overdoses are the leading cause of death in the perinatal period, more than hemorrhage or obstetrical complications (Frankeberger J et al, Matern Child Health J 2023;27(7):1140–1155).

CATR: And what can our role be, as clinicians?

Dr. Johnson: Health care providers need to educate patients about the importance of SUD treatment and the risks associated with forgoing it. Almost all patients have the same priority: having a healthy and happy baby. Getting proper substance use treatment during pregnancy is the best way to make that happen. We’ve all heard the statement “buprenorphine or methadone is substituting one drug for another; it’s not really being clean.” We need to tackle this misconception head on. Explain that there is a big difference between getting an opioid agonist or partial agonist from a prescriber versus buying a possibly contaminated drug from an illicit source.

CATR: How do you go about working with these patients in the clinic?

Dr. Johnson: Many are scared, worried, ambivalent—all the emotions that anyone starting their recovery journey might feel, but magnified. I begin by acknowledging these feelings and their legitimacy. Patients are feeling guilt about exposing their future child to substances; they may feel shame or embarrassment about their situation. I start by praising them: “This is a hard journey. We’re here to give you the support you need. How can we help?” I’ve found that framing the situation this way from the outset sets the stage for more effective work in the future.

CATR: And how do you respond when patients fear being separated from their baby?

Dr. Johnson: Again, I start by acknowledging whatever emotional reaction they’re feeling. I return to the theme of treatment being the best way to have a healthy baby. But I also find that we can take a practical approach. I say to them “What can we do to make the best of this tough situation and demonstrate to CPS that you’ll be a good parent?” The things that give CPS confidence in a patient’s ability to provide a good home for a child are the same things that we recommend as health care providers. Despite those few outlier horror stories, CPS generally looks more favorably on buprenorphine than illicit opioids. I also stress the importance of good prenatal care—keeping regular obstetrical appointments, receiving other medical treatment, taking care of mental health issues.

CATR: Any other tips for talking to patients about CPS?

Dr. Johnson: Establishing trust is essential. We usually know when we’re going to have to notify CPS. Tell your patient ahead of time; let them know what to expect. CPS is not involved when the patient is pregnant but will be as soon as the notification is made. It shouldn’t seem like going behind your patient’s back. I sometimes say “Let’s make this call together.” It can be a tough conversation, but addressing it preemptively is preferable to being blindsided right after delivery.

CATR: We’ve talked a lot about the importance of good SUD treatment during pregnancy. What does that look like?

Dr. Johnson: It lies along a continuum. Some patients have been stable in recovery for years, so for them, keeping treatment in place is the way to go. It is sufficient for some to receive regular outpatient treatment, perhaps weekly, for the duration of the pregnancy. Others are actively using and struggling to stop. For them, we consider perinatal residential treatment. These are specially designed programs that deliver addiction care to pregnant people or those who have just given birth.

CATR: Those facilities sound great, but they also sound expensive.

Dr. Johnson: Accessibility is a big issue. But that doesn’t mean elements of these programs can’t be implemented in other settings. I’m a bit spoiled with my clinic’s integrated prenatal and behavioral health care. Here, patients come to their OB appointment, see a therapist, a case manager, maybe a psychiatrist or a peer support. We educate patients about 12-step programs and other resources such as SMART Recovery. Even in settings where these services aren’t integrated, it’s key to focus on outreach, collaboration with other providers, and communication across disciplines. When possible, make referrals to local services. One silver lining of COVID is that many resources went online and have stayed online, and that helps accessibility.

CATR: What resources would you recommend for providers caring for pregnant patients with addiction?

Dr. Johnson: Familiarize yourself with local laws and regulations. There are online resources that lay out the differences (www.tinyurl.com/5n72e545). If you are unsure, call your hospital’s legal department. It’s also helpful to know community resources so you can refer your patients if needed. I would also encourage reviewing the Academy of Perinatal Harm Reduction’s online toolkit (www.tinyurl.com/wa4kracf). And finally, I recommend SAMHSA’s resources on caring for pregnant people with SUDs (www.tinyurl.com/ye4cmykn).

CATR: Thank you for your time, Dr. Johnson.