Substance abuse is affecting all segments of society. Its impact on the nation's future is seen most cleatly in its effects on women and children. Addiction among pregnant and parenting women has become a national crisis - millions of women of childbearing age are abusing drugs and alcohol and thousands of babies are born each year exposed to these substances, many of whom do not survive or have low birthweights and are fragile.1'2
IMPACT OF CRACK COCAINE
It is well known that substance abuse is a major problem in all segments of society. Recent studies have confirmed that there is no significant difference in the rate of illegal drug use between publicly and privately insured women.3,4 However, when drug use is coupled with the serious problems of poverty, its negative effects are intensified significantly. Although substance abuse is not a new problem, the introduction of crack cocaine to poor urban areas has changed the scope of the problem. Crack cocaine is one of the most addictive substances known. It is inexpensive, readily available, and particularly pernicious because it gives users feelings of power, confidence, and energy.5 Formerly, cocaine was the "champagne drug," appealing to "fast-track yuppies," but now it has also become the drug of choice for young poor women who have no other way to experience the illusions of power and control.
The impact of crack cocaine can be best understood through the all too common stories reported by health and social service providers and by mothers themselves. Their reports tell of mothers who sell their children's food for drugs, mothers who sometimes sell their children, mothers who can barely wait to finish giving birth to return to the street for drugs, mothers who forget that they have given birth, and mothers who leave their babies with grandmothers for days or weeks or longer. We are witnessing mothers who are so trapped by their addiction that they are unable to provide even the most minimal care for their families. As a result of the epidemic of substance abuse, the primary social relationship - that between mother and child - is being destroyed. Both the short-term and long-term consequences of this change are unprecedented and truly devastating to the fabric of our society.
WOMEN WHO ABUSE SUBSTANCES
Substance abuse among women is a long-standing but hidden problem. Historically, society has been reluctant to acknowledge that women are abusers - indeed, the stereotype of substance abuse is an alcoholic male. The image of women, and particularly of mothers, as substance abusers is so unacceptable that both identification and treatment of women has lagged behind that for men. Women who are identified as abusers have been labeled as morally deficient and subjected to severe public disapproval.6'7
There are very real correlates between debilitating social factors and substance abuse. Women substance abusers commonly have histories of sexual abuse, ongoing physical abuse by partners, low self-esteem, depression, and muttigenerational substance abuse. Any of these factors would be sufficient to predict difficulty in adjusting to the stresses of adult life, and in combination, they bode poorly for a woman's capacity to function as an independent adult and a mother.7'11
The findings concerning past and ongoing abuse among substance-abusing women are striking. The reported incidence of early physical and sexual abuse, including incest, is as high as 80%. A related finding is that addicted women come from dysfunctional families in which at least one parent was a substance abuser. Chemically dependent women often continue to live in violent, isolating, and dysfunctional situations as adults. Nonsubstance-abusing men usually do not stay with women who are substance abusers, and substance-abusing women who do live with men are subjected to a high level of violence.6 A study of substance-abusing pregnant women revealed that 70% reported being beaten as adults. Of these women, 86% were beaten by their husbands or partners, and the remainder were beaten by other family members, family friends, or strangers.10
Depression is also common among substance abusers. A study of over 500 opiate-dependent persons in treatment showed that 70% of the opiate addicts had a psychiatric disorder at some point in their lives and of these, almost 87% had a major depressive disorder that was separate from addiction.11'12
PUNITIVE RESPONSES TOWARD PREGNANT AND PARENTING WOMEN
Deeply held cultural prohibitions and negative stereotypes affect decisions concerning the epidemic of substance abuse. In contrast to the provision of services to other individuals who are ill because of the consequences of their life-styles (eg, tobacco and high-fat diets), public initiatives have been directed toward punishing mothers and pregnant women who abuse substances. More than 50 women have been charged criminally for using drugs during pregnancy. Prosecutors have employed a variety of child endangerment statutes, including delivery of drugs to a minor, ie, a fetus. At least three women have been convicted. Numerous states have amended child abuse statutes to include prenatal exposure to controlled substances or to require health professionals to report positive drug tests from mothers or infants.13
The overwhelming weight of testimony from the medical community opposes punitive measures toward pregnant or parenting women.* The fear of punishment is seen as a major barrier to access to essential health care for such women. There is evidence that fear of reprisals is more likely to keep women away from health care than from drugs.1 Documentation exists to support the efficacy of treatment, and there is no evidence that punishment - either by jailing women or automatically removing children because of toxicology reports - is a deterrent to substance abuse.
SUBSTANCE ABUSE DURING PREGNANCY
For several reasons, substance abuse in pregnancy has not been a major issue of public concern until recently. In addition to general societal reluctance to acknowledge substance abuse among women, the consequences of pregnancy on the health of mothers and infants did not receive widespread attention until the past decade. This problem was ignored largely because infants born to addicted mothers were not likely to survive.14 The combination of the unprecedented improvements in medical care for high-risk infants over the last 20 years, resulting increases in the number of surviving children of addicted women, and the recent significant increase in substance abuse among women has finally brought this problem to the attention of the public.
The most frequently cited study was done by Chasnoff in 1988 as a survey of 40 urban hospital maternity departments. Based on these limited data, he estimated that approximately 1 1 % of births were to drug-involved women. There are reports that the incidence of drug-exposed infants is significantly undercounted because hospitals do not routinely test for illicit substances. In one study, the reports of drug-exposed infants ranged from only 3% in hospitals without routine screening to close to 16% in hospitals with screening.1 Obviously, women are not pregnant most of the time; however, these data provide a window through which the extent of substance abuse among women can be estimated.
It is clear that when women are in trouble, so are their children. These data suggest that substance abuse treatment is essential to the health and welfare of families and to the future of society.
BARRIERS TO TREATMENT
The substance abuse treatment system has responded in a very limited way to the needs of women and their children. Despite public criticism regarding the lack of responsiveness to issues that are critical to successful service to women, there are few programs that meet these needs.6,16 Women are dramatically underrepresented in treatment compared with all estimates of prevalence. Conservative estimates indicate that women represent 33% of those in need of treatment, yet a national survey indicates that 80% of the treatment resources are used by men.17
Although treatment is essential for all substanceabusing women, services for pregnant women are medically urgent. However, despite well-known physiological risks, treatment for pregnant women is virtually nonexistent. National data suggest that fewer than 11% of pregnant women needing treatment actually receive it.17 A 1989 survey of treatment programs in New York City revealed that 54% of treatment programs categorically refused to serve pregnant addicts. Of the remaining programs, availability was further limited because 67% would not accept Medicaid as payment and only 1 3 % would accept pregnant Medicaid patients who were addicted to cocaine.18 These data are reflective of national patterns.
The health-care system has not combined prenatal and substance abuse services. A 1989 survey of hospitals in large metropolitan areas by the Select Committee on Children and Youth of the US House of Representatives revealed that two thirds had no place to refer substance-abusing pregnant women for treatment.1,10
Obstetrical care includes few providers who are knowledgable about substance abuse. Pregnant women are frequently denied access to substance abuse treatment because of perceived medical and liability risks. Usually, women who are participating in substance abuse treatment receive minimal or no medical or prenatal care, and they risk having service terminated when their pregnancies are discovered.
Even when drug treatment is available to pregnant or parenting women, the services are often inappropriate. The substance-abuse treatment system has been designed primarily to serve single men.19 The problems faced by women in treatment include the lack of provision for child care and treatment protocols that have been designed for men.
Traditionally, substance abuse treatment has been confrontational and punitive. Whether this model is effective for men is a question beyond the scope of this presentation, but it is clearly inappropriate for women. There is ample evidence that women substance abusers lack a sense of self-worth. Confrontational models reinforce low self-esteem, reducing the likelihood that the client can gain the strength to become free from drugs and face the serious responsibilities of economic survival while raising children. Treatment models in general use are oriented toward helping clients develop a sense of self independent of those around them, while family-centered models are more responsive to women.20
Failure to provide on-site child care constitutes an insurmountable barrier to treatment in both outpatient and inpatient settings. To enter inpatient or long-term residential treatment, women often must agree to have their children placed in foster care or with relatives. In either case, they cannot be assured that they will regain custody. Research has shown that concern over their children's welfare is a powerful motivator encouraging women to seek treatment.6 At the same time, drug-dependent women whose children have been placed in foster care are significantly more depressed than women who are able to remain with their children during treatment.11 It is well documented that moving children in and out of foster care is detrimental to their optimal development. Children can be better served in a supervised and safe environment while their mothers receive treatment.
EFFECTIVENESS OF TREATMENT
Until the past few years, there were only a handful of national programs that offered comprehensive care for women and their children. Recently, because of the crack epidemic, the federal government and several states have funded new projects. These programs are too new to provide definitive evaluation data. However, data from the few programs that have been in existence for several years suggest that comprehensive treatment programs can be effective in freeing women from drug dependence.11,16,21
Positive effects of treating substance abuse have been demonstrated for abusers of the range of addictive substances, including alcohol, opiates, and cocaine. A recent study reported a drop in the percentage of low birthweight babies from 50% to 18% as a result of appropriate treatment.11 In addition, data from pro' grams in Philadelphia and Boston show significant improvements in birth outcomes for pregnant women who participate in substance abuse and prenatal care programs.21,22
COMPONENTS OF EFFECTIVE TREATMENT
Because substance-abusing women have multiple problems, service integration must be responsive to the full range of their needs. In addition to appropriate counseling and therapy, treatment must address the issues that lead to and that maintain patterns of abuse. Substance-abusing women are likely to be facing several pressing problems, including domestic violence, depres' sion, inadequate housing, and limited financial resources and vocational skills. They also may have serious health problems caused by substance abuse. In addition, issues related to their roles as parents are critical factors in treatment. It is essential for the future of the femily unit that children's needs are identified and met as the mother receives treatment.
Professionals who provide service to pregnant and parenting addicted women at times find it difficult to provide care in a nonjudgmental fashion. Both the public and many health professionals view substanceabusing behavior, in contrast to other health-related problems, as voluntary, hostile, and destructive.23 It is, however, critical to the success of treatment that staff attitudes are positive and encouraging rather than punitive or disapproving. Because of low self-esteem and internalization of societal attitudes toward abusers, successful treatment of women is facilitated by encouragement rather than confrontation and punishment.24 In the absence of supportive staff attitudes, women may discontinue treatment.25
ROLES OF HEALTH-CARE AND SOCIAL SERVICE PROVIDERS
Because of the scope of the problem of substance abuse, it is imperative that all providers who serve women and their children are able to diagnose and refer women for treatment. Women are more likely to seek care for health and mental health problems that are related to chemical dependence rather than for the dependency itself. Therefore, their first contacts with the health-care system may be with providers of primary care, mental health care, and social services. They may describe their problems as related to child rearing and seek help from pediatricians, child-care workers, or educators. If substance abuse is not identified, psychoactive drugs that increase the risks associated with addiction may be prescribed for these women.6
The separation of the substance abuse treatment field from other health systems has had many negative consequences. Health-care providers often lack experience in accessing and working in a coordinated fashion with substance-abuse providers. In many communities, primary care providers may not know whether adequate treatment resources exist. In addition, advocacy by health-care providers is needed to ensure that adequate and effective services become available in every community.
The scope and complexity of the problem of substance abuse demands the involvement of all segments of society in fashioning workable solutions. Trie role of the medical community, in terms of practice, research, and education, is critical to assuring that substance abuse prevention, diagnosis, and treatment meet high standards. It is also essential that new systems of care are developed that will allow clients to receive critical services without artificial barriers because of limited communication, inadequate diagnosis, and social stigma.
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