Non-punitive Alcohol and Drug Treatment for Pregnant and Breast-feeding Women and their Exposed Children

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1 Non-punitive Alcohol and Drug Treatment for Pregnant and Breast-feeding Women and their Exposed Children Date: December 9, 2011 Status: Originated by: Adopted by: Revised Position Statement ANA Center for Ethics and Human Rights ANA Board of Directors Purpose: The purpose of this position statement is to reinforce the American Nurses Association s recognition that substance addiction is a treatable illness and its commitment to prevention and treatment as primary solutions to perinatal substance abuse and addiction. The threat of criminal prosecution undermines the efforts of registered nurses' encouraging women to seek prenatal care and treatment for their substance problems. Statement of ANA Position: The American Nurses Association (ANA) directs registered nurses working in the perinatal field to seek out appropriate rehabilitation and therapy treatment for women abusing substances (illicit or prescribed drugs, and/or alcohol) and to identify and offer appropriate therapy to infants exposed to these substances. The registered nurse works with social services, rather than law enforcement or the judicial system, to obtain help for the woman and infant. History/Previous Position Statements: Scope and Standards of Addictions Nursing Practice (ANA & INSA, 2004) offers excellent guidance on how nurses can best support patients with drug or alcohol addiction. One standard of care identifies the therapeutic alliance (p. 37) needed

2 for facilitation of a patient s recovery. The scope of practice statement delineates the knowledge and skills (p. 22), education (p. 26), and case management role (p. 25) of the nurse who works with these clients. Of particular note is that no form of interaction with the legal or judicial system is mentioned in this book. The content is based solely on advocacy. Advocacy is supported by ANA s Code of Ethics for Nurses with interpretive statements (2001), in interpretive statement 1.2, Relationships to Patients, which states: The need for health care is universal, transcending all individual differences. The nurse establishes relationships and delivers nursing services with respect for human needs and values, and without prejudice. An individual's lifestyle, value system and religious beliefs should be considered in planning health care with and for each patient. Such consideration does not suggest that the nurse necessarily agrees with or condones certain individual choices, but that the nurse respects the patient as a person. Supportive Material Substance abuse is the indulgence in and dependence on a drug or other chemical leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others. ANA recognizes substance addiction as a treatable illness and is committed to prevention and treatment as primary solutions to perinatal substance abuse and addiction. Addiction is a primary disease requiring specialized treatment to achieve long-term behavior change known as recovery. The threat of criminal prosecution prevents many women from seeking prenatal care and treatment for their substance problems. Few alcohol and other drug abuse treatment services are presently available for pregnant women, and few programs are designed specifically for women of childbearing age, due to a perceived risk of liability in caring for the unborn child and/or state-level regulations. ANA Position Statement Page 2

3 ANA recognizes that nurses in maternal child services may not be fully educated in the needs of patients with substance abuse problems and the special needs of infants experiencing neonatal abstinence syndrome (NAS), previous called withdrawal. Women struggling with addictions require increased patience and advocacy by nursing staff in caring for their infants (Murphy- Oikonen, Brownlee, Montelpare, & Gerlack, 2010). Nurses are encouraged to seek educational programs that offer additional training in mental health and drug addiction fields. ANA acknowledges that socioeconomics, class, race, and ethnicity may influence how women are cared for in the maternal child setting related to this issue, and compels fairness in drug screening, treatment, and rehabilitation services. Both the mother and infant are objects of care and concern for the nurse (Hulsey, 2005). Many nurses are mandated to report infant-related substance exposure by their State Boards of Nursing. ANA acknowledges this mandate and asks that this reporting be accompanied by enrollment of the mother in drug rehabilitation treatment. In addition to providing drug and alcohol treatment for pregnant women and their children, appropriate care must be given to the special needs of newborn infants experiencing NAS, which is a generalized disorder characterized by signs and symptoms of central nervous system hyperirritability, gastrointestinal dysfunction, respiratory distress, and autonomic symptoms such as sneezing, yawning, sweating, stuffy nose, mottling, and fever (Finnegan, Reeser, & Connaughton, 1977). Infants need to be accurately assessed for signs and symptoms of neonatal abstinence and provided with comfort measures and pharmacologic management, if needed. Social services may need to be involved to ensure that the infant will be discharged into a nurturing environment. Every effort should be made to keep the mother and infant together. However, the ANA Position Statement Page 3

4 passing of substances via breast milk must be well understood, and appropriate nutrition for the infant must be available. Infants at risk for abstinence syndrome and who must be closely monitored include those whose mothers: Are known to have abused substances Are in medical recovery with methadone or buprenorphine (Suboxone/Subutex) Entered prenatal care late or did not enter it at all Experienced a placental abruption Delivered preterm and/or precipitously Have a history of chronic pain treatment Infant assessment can be done using standardized tools. One tool often used is the Finnegan Scoring System, which measures the degree to which infants experience symptoms of substance abuse withdrawal and provides a means for appropriately diagnosing NAS. This instrument is a list of 21 signs and symptoms of neonatal withdrawal that are scored and assessed throughout the period of withdrawal (Finnegan, Kron, Connaughton, & Elich, 1975). Infant assessment can also be provided with the Lipsitz tool, which offers the advantage of being a relatively simple numeric system with good reliability. (American Academy of Pediatrics Committee on Drugs, 1998; Lipsitz, 1975). An additional assessment tool is the Neonatal Withdrawal Inventory developed by Zahorodny and colleagues (Zahorodny et. al, 1998). Criminalization of substance-abusing mothers often results in more harm than good. Prisons are not prepared to provide for the specialized needs of pregnant women (Stephany, 1999; d Arlach, Curtis, Ferrari, Olson, & Jason, 2006). Women are seven times more likely to enter ANA Position Statement Page 4

5 prison with histories of untreated post-traumatic stress, sexual abuse or assault, and depression which they reported self-medicating with alcohol and/or drugs (Alleyne, 2006). Multiple cases of prenatal neglect in correctional facilities have been documented by Amnesty International (Eliason & Arndt, 2004). A national survey of services for pregnant inmates in state prisons found that fewer than half have written policies to address the care of pregnant women, fewer than half offer any prenatal services whatsoever, and only 16% have additional services such as Lamaze classes, special diets, and reduced or no-work policies (Seifert & Pimlott, 2001). Additionally, wardens surveyed reported problems such as inadequate resources to cope with miscarriages and preterm labor, no maternity clothes, belly chains during transport to the hospital for delivery, the housing of minimum security pregnant inmates in maximum security facilities, absence of a place for mother and infant to remain together, absence of separate visiting areas for mothers and newborns, and overcrowded living conditions (Seifert & Pimlott, 2001). There is a higher than normal miscarriage rate among pregnant inmates secondary to inadequate prenatal care, drug withdrawal treatment, poor nutrition, loss of social support networks, and stress of incarceration (Eliason & Arndt, 2004). High perinatal morbidity and mortality have been documented in studies of the birth outcomes of incarcerated mothers, including fetal and neonatal death, intrauterine growth retardation, preterm labor and delivery, and required neonatal intensive care unit admissions (Seifert & Pimlott, 2001). Furthermore, research has demonstrated that drugs are readily available in prisons (Stephany, 1999; Seifert & Pimlott, 2001; d Arlach et al., 2004). Treatment has been found to be a more effective tool than incarceration to reduce and eliminate substance abuse and provide a healthier perinatal environment for children (Stephany, 1999; ANA Position Statement Page 5

6 ACOG, 2005; d Arlach et al., 2006; Alleyne, 2006). Women who are separated from loved ones, under stress, and lack adequate addiction treatment are not likely to remain abstinent, completely defeating the purpose of drug-use prevention and protecting the fetus. Programs with live-in services for mothers and their children, on the other hand, have reported decreased criminal activity, increased self-esteem, and improved parenting relationships (d Arlach et al., 2006). Many states require treatment rather than incarceration at this time (Guttmacher Institute 2011). (Batki, Kaufman, Marion, Parrino, & Woody, 2005). Treatment rather than incarceration has been advocated by many professional and community-based organizations, including the American Public Health Association, American College of Nurse Midwives, National Perinatal Association, March of Dimes, American Society of Addiction Medicine, American Civil Liberties Union, Center for Reproductive Law and Policy, National Association for Perinatal Addiction Research, National Association of Public Child Welfare Administrators, Center for the Future of Children, American Nurses Association, Southern Summit on Healthy Infants and Families (Stephany, 1999), and American College of Obstetricians and Gynecologists (ACOG, 2005). Additionally, the International Society of Psychiatric-Mental Health Nurses and Society for Addiction Medicine have new positions on referrals to treatment for this disease state. Although the use of alcohol during pregnancy is not illegal, the harm of this substance is well known. Alcohol is considered a toxin to fetal cellular development. Infants with Fetal Alcohol Syndrome meet the criteria for Part C of the Individuals with Disabilities Education Act and are entitled to specialized developmental services. Newborns can be distinguished by a characteristic pattern of features (Wattendorf & Muenke, 2005), which may include shortened palpebral fissures, a smooth lip philtrum, thin vernmillion border of the upper lip, underdeveloped upper portion of the ears, and/or epicanthal folds. ANA Position Statement Page 6

7 Recommendations ANA supports a marked increase in funding at federal, state, and local levels for development and expansion of alcohol and other drug abuse treatment services tailored to meet the special needs of women of childbearing age and their children. ANA supports the fact that alcohol and drug abuse/misuse is a disease that requires treatment and not incarceration. Women who abuse drugs during pregnancy require treatment from a rehabilitation program that provides drug addiction education, parenting skills, substance abuse counseling, health education, drug use prevention activities, and life skills. ANA also supports that infants exposed to drugs and/or alcohol in utero be assessed for signs and symptoms of neonatal abstinence and receive pharmacologic treatment when needed. Potential exists for fetal alcohol syndrome as well, and nurses should be aware of how to identify infants with this problem. For these families, referrals are essential. There is an urgent need for nursing and other research designed to improve the knowledge base upon which prevention and treatment efforts are based and to test innovative interventions tailored to women of childbearing age. Summary: The registered nurse has the role of identifying those women and infants who are in need of drug or alcohol treatment. The nurse is not an instrument of the judicial or legal system in his or her role as patient advocate. Supersedes: Position Statement: Opposition to Criminal Prosecution of Women for Use of Drugs while Pregnant (04/05/91) ANA Position Statement Page 7

8 References American Academy of Pediatrics Committee on Drugs. Neonatal drug withdrawal (1998). Pediatrics, 101, American College of Obstetrics and Gynecology, Committee on Ethics (2005). Maternal decision making, ethics, and the law. Obstetrics and Gynecology, 106, American Nurses Association & International Nurses Society on Addictions (2004). Scope and standards of addictions nursing practice. Washington, DC: Nursesbooks.org. American Nurses Association (2001). Code of Ethics for Nurses with Interpretive Statements. Washington, DC: American Nurses Publishing. Alleyne, V. (2006). Locked up means locked out: Women, addiction and incarceration. Women & Therapy, 29 (3/4), Batki S. L., Kauffman J. F., Marion I., Parrino M. W., Woody G. E. (2005). Center for Substance Abuse Treatment (CSAT). Medication-assisted treatment for opioid addiction in opioid treatment programs. Medication-assisted treatment for opioid addiction during pregnancy. Rockville, M.D.: Substance Abuse and Mental Health Services Administration (SAMHSA), Treatment improvement protocol (TIP) no. 43, d Arlach, L., Curtis, C. E., Ferrari, J. R., Olson, B. D., & Jason, L. A. (2006). Substance abusing women and their children: A cost-effective treatment option to incarceration. Journal of Social Work Practice in the Addictions, 6(4), Eliason, M. J. and Arndt, S. A. (2004). Pregnant inmates: A growing concern. Journal of Addictions Nursing, 15, ANA Position Statement Page 8

9 Finnegan, L. P., Kron, R. E., Connaughton, J. F., & Emich, J. P. (1975). Neonatal abstinence syndrome: Assessment and management. Addictive Diseases: An International Journal 2(1), Finnegan, L. P., Reeser, D. S., & Connaughton, J. F. (1977). The effects of maternal drug dependence on neonatal mortality. Drug and Alcohol Dependence, 2, Guttmacher Institute (2011). Substance Abuse During Pregnancy. Hasenecz, N. M. (2010). Pregnant and postpartum women in addiction recovery: Treatment that works. Social Work Today, 10(4), 10. Hulsey, T. (2005). Prenatal drug use: The ethics of testing and incarcerating pregnant women. Newborn and Infant Nursing Reviews, 5(2), Lipsitz, P. J. A. (1975) Proposed narcotic withdrawal score for use with newborn infants. A pragmatic evaluation of its efficacy. Clinical Pediatrics, 14, Murphy-Oikonen, J., Brownlee, K., Montelpare, W., & Gerlack, K. (2010). The experiences of NICU nurses in caring for infants with neonatal abstinence syndrome. Neonatal Network; The Journal of Neonatal Nursing, 29 (5), Seifert, K. and Pimlott, S. (2001). Improving pregnancy outcome during imprisonment: A model residential care program. Social Work, 46(2), Stephany, T. M. (1999). The pregnant addict: Treat or prosecute?: implications for midwifery management. Journal of Nurse-Midwifery, 44(2), Wattendorf, D. J. & Muenke, M. (2005). Fetal Alcohol Spectrum Disorders. American Family Physician, 72(2), ANA Position Statement Page 9

10 Zahorodny, W., Rom, C., Whitney, W., Giddens, S., Samuel, M., Maichuk, G., & Marshall, R. (1998). The neonatal withdrawal inventory: A simplified score of newborn withdrawal. Journal of Developmental & Behavioral Pediatrics, 19(2), Example of case involving prosecution is that of Regina McKnight. ANA Position Statement Page 10

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