Woe Is Me! What Can We Do About Drugs?
One of the problems of being the editor of a medical journal, such as Pediatrie Annals, is that all too often you have to sit down and write an editorial on a depressing subject - one that is being focused on in that month's issue. Acquired immunodeficiency syndrome (AIDS) in children, the effects of behavioral problems on families, sexually transmitted diseases and pregnancy in adolescents, and the problems related to day-care attendance are examples. The subject of this month's issue on substance abuse during pregnancy, compiled by our guest editor, Reginald C. Tsang, MD, is one of the most depressing subjects of all. The magnitude of the problem is enormous, and its medical and social implications are staggering.
A recently published review of the problem by the Alcohol, Drug Abuse, and Mental Health Administration summarized the most recent findings of basic research and clinical studies conducted on the effects of alcohol, tobacco, and other drugs on the unborn, on the mother herself and on the baby after birth through lactation.1 AH of these findings are included in the six articles appearing in this issue of Pediatrie Annals. Unfortunately, estimates of the extent of substance abuse during pregnancy derived from studies conducted to date are difficult to interpret because no large-scale surveys have been conducted. We therefore have relied on data from maternal histories and infant birth records collected by individual hospitals and perinatal research centers, which often use different methodologies. In 1990, the Centers for Disease Control (CDC) and the National Institute on Drug Abuse (NIDA) initiated surveys of in utero drug exposure, which promise to define better the magnitude of this problem and how we can deal with it. Current data indicate that:
* 60% of women of childbearing age drink alcoholic beverages; 10% consume an average of two drinks or more a day - an amount sufficient to cause fetal alcohol syndrome.
* 25% of women smoke cigarettes during their pregnancy.
* 10% of women of childbearing age admit to using illicit drugs; 1 1% of new mothers (whether wealthy or poor) use cocaine, marijuana, heroin, methadone, amphetamines, or phencyclidine (PCP) during pregnancy.
* 1% to 11% of newborn babies (40 000 to 375 000 annually) have been exposed to illicit drugs in the immediate antenatal period; these figures do not include exposures to alcohol or nicotine.
Most experts in the field of substance abuse during pregnancy agree that the CDC and NIDA surveys will show that these prevalence estimates are low; indeed, an NIDA household survey of women conducted between March 12, 1990 and June 30, 1990 showed that 4-5% admitted to using cocaine during pregnancy, 17.4% to using marijuana, 37-6% to smoking cigarettes, and 73% to drinking alcohol.2
The medical consequences of substance abuse during pregnancy to the newborn include spontaneous abortion; premature birth, low birthweight, and smallfor-gestational-age length and head circumference; central nervous system damage that may delay or impair neurodevelopment; teratogenic physical malformations; withdrawal effects; and an increased incidence of sudden infant death syndrome. Social consequences of substance abuse include broken families; child abuse, neglect, and abandonment; joblessness, poverty, and dependence on public assistance; foster care, kinship care, and adoption; and the need for comprehensive, coordinated treatment programsThe inaugural issue of The Future of Children, published by the Center for the Future of Children of the David and Lucile Packard Foundation, was devoted to the problem of drug-exposed infants. The Center's staff made the following recommendations for a national policy in response to this problem3:
* Pregnant women should receive prenatal care and education about the risks of using drugs, alcohol, and tobacco during pregnancy.
* Drug treatment programs should be available for all drug-abusing pregnant women and parents of infants, and these programs should be responsive to other related needs of these families.
* An infant should be considered drug-exposed and in need of some level of intervention if the mother states that she has used illegal drugs during pregnancy or if drug exposure is shown through urine or blood tests of the infant. Such tests should be administered only if there is a recent history of maternal drug use or if the medical conditions of the mother or infant indicate that testing is needed for diagnosis or treatment.
* When an infant is identified as drug-exposed, the infant and his or her family should be assessed by health providers (with assistance when necessary from developmental, drug treatment, and other specialists) to determine what intervention, if any, is needed.
* Health and developmental services should be available to all identified drug-exposed infants as needed. Parenting education and other support services should be available to their parents as needed.
* An identified drug-exposed infant should be reported to child protective services only if factors in addition to prenatal drug exposure show that the infant is at risk for abuse or neglect.
* Barriers to child protective services' capacity to meet the requirements of current child welfare laws should be identified and removed. These barriers might include high caseloads, lack of drug treat' ment and support services for the families, backlogs in the courts, and inadequate numbers of foster or adoptive homes.
* A drug-exposed infant should be removed from the custody of his or her parent(s) only if the parent(s) is unable to protect and care for the infant and either support services are not sufficient to manage this risk or the parent(s) has refused such services. If the parentfs) is not capable of resuming custody of the infant within 12 to 18 months, despite receiving services to make reunification possible, a permanent, alternative placement should be promptly provided for the infant.
* A woman who uses illegal drugs during pregnancy should not be subject to special criminal prosecution on the basis of allegations that her illegal drug use harms the fetus, nor should states adopt special civil commitment provisions for pregnant women who use drugs.
* Research should be supported to determine the prevalence of illegal drug use among pregnant women, the relationship between such use and birth and developmental outcomes, and the effectiveness of drug treatment and intervention programs. Special focus should be given to evaluating drug treatment programs for pregnant women and parents with infants for their effectiveness in enabling participants to function as adequate caretakers of their children.
No one would argue with these recommendations. If these recommendations were all implemented, the medical and social consequences of substance abuse during pregnancy would be greatly reduced, perhaps to an irreducible minimum. However, the prospects for finding the resources to implement these recommendations are not bright, and the recommendations do not include actions that will reduce in the foreseeable future the likelihood of women becoming substance abusers in the first place. The reasons these women abuse drugs are intermeshed with our societal structure, which is being eroded by family discord and dissolution, physical and sexual abuse of children and adult women, and poverty and despair. These are problems whose solutions are beyond the scope of medical and social service practitioners alone, except as they might influence change for the next generation by application of the Center for the Future of Children's recommendations.
Some propose controlling today's dnig problem through escalating the war on drugs by sealing our country's borders to drug importation. This, however, has proven too costly, and even if it were adequately financed and successful, new drugs, easily and cheaply manufactured domestically, such as "ice" (smokable speed) and "tango and cash" (3-methyl fentanyl), would replace imported drugs, and they are more powerful and lethal than the illicit drugs currently in use. The war on drugs includes law enforcement directed to suppliers and users of illicit drugs, but this too has been costly and unsuccessful and has led to the critical overcrowding of our prisons and the need to build more prisons to house convicted drug-abuse felons.
Some believe the sale of all drugs should be legalized, arguing that: 1) anyone who wants drugs today can easily buy them illegally; 2) other countries where drugs have been legalized have not witnessed an increase in drug use; 3) if the sale of tobacco and alcohol are legal, the sale of illicit drugs also should be because tobacco kills 350 000 Americans annually and alcohol 100 000, while illicit drugs only kill 5000 (most of these deaths are a result of the toxic effects of adulterated street drugs; however, many more than this number die each year in drug-related crimes against innocent persons, in drug dealer turf battles, and in the course of enforcing drug laws); 4) our inner-city communities are being destroyed by drug trafficking and a whole generation of their young inhabitants are among its victims; and 5 ) illegal drug use enhances the spread of AIDS through the use of contaminated needles and syringes; this would be greatly reduced if cheap, disposable needles and syringes were legally available to drug users.
The lessons learned from Prohibition, which banned the sale of alcohol in the United States in the 1920s and the early 1930s, are not well-remembered despite the exploits of Elliot Ness and his "Untouchables" who battled bootleggers Frank Nitti and Al Capone in the streets of Chicago and in the movies and on television. Most important, Prohibition did not decrease the use of alcohol; furthermore, homemade, high proo£ toxic "moonshine" and "bathtub gin" caused many deaths that would not have occurred if the sale of alcohol had been legal.
Despite all these reasons, it is unlikely that the sale of addictive drugs in the United States will be legalized soon, if ever. Perhaps if our society continues to fell apart at its undersuriace, this step will be taken, along with political and economic reforms designed to strengthen, succor, and sustain the people who live on that undersurface. Let's hope so.
1. Cook PS. Petersen RC, Mouie DT. In: House TB, ed. Alcohol, Tobacco and Otfier Drugs May Harm the Unborn. Office of Substance Abuse Prevention, Alcohol, Drug Abuse, and Mental Health Administration. Washington, DC: US Government Printing Office; 1990. US Dept of Health and Human Services publication ADM 90-1711.
2. National institute on Drug Abuse. Naatmai Household Survey an Drug Abuse: Population Estimale 1990. Washington, DC: US Government PrintinE Office; 1991. US Dept of Health and Human Services publication ADM 91-1732.
3. Center fat the Future of Children. Recommendations. In; Behrman RE, ed. The Future of Children: Drug Exfnsed infants. Los Altos, Calif: David and LJJC ile Packard Foundation; 1991.