Tennessee is the first state in the nation to have a law criminalizing pregnancy outcomes. The state's pregnancy criminalization law was signed in April and went into effect this month. Under the new policy, prosecutors can now charge a woman with criminal assault if she uses narcotics during her pregnancy and -- according to the language of the law -- her fetus or newborn is considered "addicted to or harmed by the narcotic drug."
Earlier this week, the first woman in the state was arrested under the new law -- two days after she gave birth to her daughter. The policy has been denounced by doctors and major medical associations, but conservative state lawmakers have nonetheless cloaked it in the language of medical necessity and compassionate treatment. When asked about concerns that the state's rejection of the Medicaid expansion and a lack of treatment facilities throughout Tennessee would result in the disproportionate incarceration of low-income women in rural areas, Republican state Rep. Terri Lynn Weaver told Salon, "We’re not about jailing a bunch of women and throwing away the key -- we’re about getting them help."
But what does help actually mean? Weaver and others have cited the number of babies in the state born prenatally exposed to narcotics -- some who experience something called neonatal abstinence syndrome -- as the force behind the measure. But like the so-called crack baby epidemic before it, a profound misunderstanding of NAS, pregnancy and addiction has shaped the narrative around these issues. And the good science -- about addiction, treatment and recovery -- has receded into the background. Instead of medically accurate information about substance dependence and recovery, language about babies "born addicted" to drugs and talking points about women struggling with addiction being the "worst of the worst" prevail. In conversation with Salon, Weaver deemed the limited availability of drug treatment and healthcare in her state an entirely distinct issue from the new law. “I don’t know what to say about [how] some [women] have insurance and some do not," she said of the lack of healthcare. "It’s a terrible thing, but I don’t want to get into that because that’s another subject."
But if you listen to doctors and other experts, it's not another subject. And this ignorance from lawmakers has guided a lot of dangerous policy, which is why Salon reached out to Dr. Hendree Jones, Ph.D., a professor with the Department of Obstetrics and Gynecology at the University of North Carolina School of Medicine and an expert on neonatal abstinence syndrome and other issues related to pregnancy and addiction.
Our conversation has been condensed and lightly edited for clarity.
What exactly is neonatal abstinence syndrome?
Neonatal abstinence syndrome can happen from a variety of substances, but it's most commonly related to prenatal exposure to opioid agonists. So opioid agonists can include prescription medications like Oxycontin or Vicodin. It can also include medications that are treatments for opioid use disorders, like methadone.
Really any kind of full or partial opioid agonist like heroin can result in a baby having neonatal abstinence syndrome. It doesn’t happen with every single baby who is opioid exposed. It really depends on a whole bunch of factors, some of which we don’t even fully understand. Some of the babies might need treatment for their neonatal abstinence syndrome, and other babies don’t.
And what does it look like in the babies who do have it?
It's basically three components. There are central nervous system changes, there are autonomic changes and there are gastrointestinal changes.
This means that babies might have more trouble sleeping than other babies who aren’t opioid exposed, so they might sleep less. They might cry more or be more irritable, which means if you go to touch them, they might grimace, and sort of shrink away from your touch. They might also have sneezing, some tremors and things like diarrhea or tummy effects. They could have problems breathing. Babies who have neonatal abstinence syndrome can take more time and care, take longer to feed. They can be more difficult to console and calm down than babies who haven’t been opioid exposed.
And are these symptoms treatable?
Neonatal abstinence syndrome is a treatable condition, and I think that it's really important to say that. It is treatable. What you would hope would happen is that when Mom comes in, that the hospital system would be prepared in knowing that there is an opioid exposure. This is kind of an expected issue that can happen with some babies that have been born prenatally exposed to opiates.
After a baby is born he or she would start to be assessed with a tool -- a checklist, basically -- that’s going to look at things like how the baby is sleeping, how the baby is eating. Are there disturbed or undisturbed tremors? Is there a lot of crying and irritability? Is there diarrhea? Is there a lot of moving around where the baby might get excoriations -- hurt skin -- from rubbing his or her elbows or heels too much?
And so knowing that, if you're assessing the baby every three to four hours with the feed, then, what we’ll be able to see is what medication would really help that baby to stabilize his or her autonomic and central nervous system, and help calm the irritability in the gastrointestinal tract. That will help the baby sleep better, help the baby have an easier time feeding. And then slowly -- once that medication is used to reduce the signs and symptoms and have a lower score for the baby -- then that medication is slowly withdrawn over a series of days. But always looking, every three to four hours, to assess how the baby is doing.
A lot of what I've read on the issue uses the language of addiction -- this idea that babies are "born addicted" as a result of prenatal exposure to a substance. But it doesn't seem like that is appropriate here.
It is not appropriate. Babies cannot -- by definition of addiction -- be addicted. They have not had a life course long enough where they would be using a substance in an uncontrollable way. So when babies are born, they can be born dependent on a substance. So they can be born dependent on opiates, but certainly not addicted to opiates.
This is not how the lawmakers and law enforcement officials who support measures like the Tennessee law criminalizing pregnancy outcomes tend to talk about drug use during pregnancy. But the information is out there, it's just the people making policy don't seem to be interested in it. Do you think stigma plays a role here?
I absolutely do think that stigma plays a role. I think that we need to be treating addictions as a medical health illness and not using laws to incarcerate women. My fear is that more women will be shunning the medical system and then will not be getting prenatal care. They won’t be engaging in drug treatment because they’re scared that the drug treatment will potentially turn them in. I think that laws to criminalize pregnant women could actually make the situation worse, because the women will feel like they have no safe place to turn to if they do want treatment.
The other problem is that criminalizing this overlooks the lack of access to treatment. And treatment should not just be a medication, it needs to be medication with other behavioral health components. And so where are the resources in Tennessee for women to know where to get treatment? And how are people defining treatment? We know that methadone and other treatments are not cures on their own -- for them to work you need to be receiving them as part of a larger health program to help with behavioral issues that also go hand in hand with addiction.
A pregnant woman undergoing methadone maintenance treatment was incarcerated in Texas this week and denied her medication for two full days. Similar to neonatal abstinence syndrome, I think there's a lot of false information -- or at least major misunderstandings -- out there about pregnancy and addiction treatment.
Particularly with methadone, we have huge amounts of scientific data to support the efficacy of this treatment. I would say that methadone is actually the most studied medication we have during pregnancy. So we know that when it’s given in adequate doses daily, and in the context of prenatal care as well as other forms of behavioral healthcare, it works. And it helps to minimize and stop in many cases the misuse of opiates.
We also know that when you abruptly discontinue medication, it can endanger the fetus. It can set you up for -- if you’re in your first trimester -- it can set you up for a miscarriage. And if you’re in your second trimester, it can set you up for a premature delivery, which certainly wouldn’t be in the mom or the fetus’ best interests.
If you could envision a system -- in terms of treatment and policy initiatives -- that actually helps women in these situations, what would it look like to you?
Rather than imposing a law, what I’d really like to see is the focus of resources on expanding treatment, to making treatment better quality and ensuring that women truly do have access to treatment. I think there should be more resources that are given to prevention of substance use disorders. It’s not just enough to say once in fourth grade, "Here you go, drugs are bad." We really need to be looking at prevention like we look at sunscreen, so that every time you go out, you put it on.
And so looking at how we can infuse accurate health information about substances from kindergarten all the way through high school, and also ensure that we do have that access to treatment for all women who are looking for that type of care. In the United States, when we had one of the lowest rates of drug use, we also had the highest rates of opportunity for treatment. And we’ve backslid some from the 1970s.
I also think that the way hospitals approach and treat neonatal abstinence syndrome can really dictate the severity and length of the stay of the children who have it. There are many hospitals that treat all their children in the NICU. And if they don’t have a specialized neonatal abstinence informed treatment approach, the babies are there. They’re separated from their mothers, so they’re not getting the skin to skin contact, which we know is going to help reduce the severity of the NAS. The lights are on, there’s a lot of noise, there’s a lot of stimulation. And children that have NAS need less stimulation, they need to be close to their moms with their skin, they need to be swaddled, they need to be in a dark room, they need to have minimal noise. So a lot of the ways that we treat, or fail to treat, NAS from an environmental standpoint can really make it worse. And then drive the length of stay and the need for medication for much longer.
I also think that culturally there is just a misunderstanding about people’s capacity as parents if they are also drug users or in recovery from drug use. So in some ways, the policies are all punitive because there's a fundamental assumption that these women are somehow villains.
Lynn Paltrow from National Advocates for Pregnant Women has said, "A urine test is not a parenting test." We know that substance use disorders cut across all socioeconomic strata. I think we need to be looking at the many indicators of healthy parenting. Substance use could be a part of that, but it’s only one small part of the many other factors that go into what is going to help the child and the parent be able to parent together in healthy ways.
I think that also leads to this other discussion of how do we help our young women and our young men become good parents. Not everybody is lucky enough to grow up in a family where they have good role models, so where are the resources that we’re putting to help children before they have their own children? How can they be the best parents they can be?
There was a turning point in the narrative around the so-called crack baby epidemic, where the research really made clear the fact that the problem here was poverty -- structural, systemic problems -- not exposure to cocaine in the womb. Do we have similar data on prenatal exposure to opiates?
There was a recent meta-analysis that was just published in a British journal, and they took the literature that had looked at kids up to age 5, and they did not find the terrible damaging, detrimental consequences they’d been hearing. So they actually found no differences between unexposed kids and prenatally opioid exposed kids in terms of development, in terms of cognition, leading up to 5 years of age. So I think that, in part, the media is looking for sensational stories, and because with neonatal abstinence syndrome you can see it, it engenders a lot of passion and belief about women who are using drugs when they’re pregnant.
But I think in the vast majority of data that we have, what’s most important is the environment in which the children grow up. Yes, prenatal exposure to anything, be it alcohol, tobacco, as well as opiates and amphetamine, it’s one of many factors that are going to promote or hinder resilience in the child. But what we found in our research collectively as a research group, is that by far it’s the post-natal environment, the psychological status of the caregiver, the nutrition that the child is exposed to, the other parts of the home environment. We've found that things like how much quality interaction with the caregiver that child is having will be much more predictive than prenatal drug exposure by itself.
Why do you think we tend to focus punitively on the drug use -- on punishing women for their drug use -- rather than these other factors?
I think probably the reason why is because it’s an immediately observable thing. So when the woman is pregnant you don’t see the baby. When the baby comes you immediately see it. You can see within 72 hours typically, you’ll see the expression of neonatal abstinence syndrome, whereas the expression of poverty and challenges in parenting that are then later expressed in behavioral issues with children, with poor nutrition that’s later expressed with developmental or attentional issues, they’re slower things, and so it’s much harder to pinpoint those.
And I think as a society our attention spans are getting shorter. And so you see something, and you want a quick fix, and there isn’t a quick fix. Addiction that happens in women and men doesn’t happen overnight, it happens slowly over time. And you can’t fix it overnight, you have to shape the behavior and treat the illness with care and effort over time.
And these laws that criminalize and incarcerate women ultimately separate moms from their children. Does your research look at the impact of that separation?
Certainly from the baby’s standpoint, and specifically from the standpoint of neonatal abstinence syndrome, we know this from data from Johns Hopkins, that when Mom and baby room together, the rates of just the need to treat neonatal abstinence syndrome at all -- so how many babies actually need medication -- we can cut in half.
At Hopkins we went from a 50 percent NAS rate to a 25 percent NAS rate, just by having Mom and baby room together. So there’s a tremendous amount that happens in the first couple of weeks and months in being close together. Obviously if Mom is separated the baby won’t have the benefit of breast milk and we know that that’s the most optimal nutrition for the baby in terms of acquiring Mom’s immunity to things as well as enhancing brain development and overall physical growth and reducing opportunities for illness. And then for the mom, we also know that moms are more likely to relapse if they’ve lost their children to Child Protective Services or separated in some way, so that can be really devastating too.
I think part of the learning opportunity for everyone is what in the addiction treatment community, we have an opportunity to do a better job to help educate healthcare providers as well as the public about what addiction treatment is and what recovery looks like. Because I think even in medical school physicians get very few hours of addiction education. So I think just because you’re a doctor doesn’t mean you necessarily know how to treat every single issue that comes through the door. I think part of that legislation piece needs to be education and mandating more education for any kind of healthcare provider that’s in the field, they need to be prepared to see people who have substance use disorders and know how to at least identify it and where to refer people for treatment. And the treatment has to be there for people to go to.