An NPR story (New Hampshire Mothers Struggling with Opioid Addiction Fight to Keep their Children) aired on June 2, 2018, introduced us to Jillian Broomstein, a New Hampshire mother whose two-week-old infant was removed from her by the state’s child welfare agency. Broomstein was on methodone to combat her addiction to heroin and it was working. She had not taken heroin for months.
Methadone is one of the two medications that is used in Medication Assisted Treatment (MAT) for Opioid Use Disorder. MAT is “the use of medications in combination with counseling and behavioral therapies to provide a whole patient approach to the treatment of substance use disorders.” The medications commonly used to treat opioid addiction in pregnant women include methadone and buprenorphine.
Research has shown that MAT is the most effective treatment for opioid use disorder, at least doubling the rates of abstinence from opioids compared with treatments that use a placebo or no medication. MAT has been recognized by the World Health Organization as the most effective treatment for opioid use disorder. Moreover, MAT is the treatment the American College of Obstetricians and Gynecologists (ACOG) recommends for pregnant women with opioid use disorder.
Concerns about MAT for pregnant women arise from the fact that their infants may experience neonatal abstinence syndrome. But as the lead author of the ACOG guidance states, “Concern about medication-assisted treatment must be weighed against the negative effects of ongoing misuse of opioids, which can be much more detrimental to mom and baby.” MAT increases adherence to prenatal care and drug treatment and reduces the risk of pregnancy complications. Abrupt withdrawal from opiates or safer substitutes means a mother is more likely to relapse, thus making it less likely that she can reunify with her child. Neonatal abstinence syndrome, on the other hand, is treatable and does not appear to have lasting effects.
Bias against MAT among professionals working with substance-abusing families has been documented often. An excellent federal study, discussed in an earlier post, found that MAT is not always understood or accepted by child welfare professionals, judges or even in the substance abuse treatment community. One reason for such bias may be that many professionals have past experience with other types of drugs such as cocaine and methamphetamine, for which MAT is not available
Information on state policies regarding reporting, investigation, and placement of infants exposed to methadone and buphrenorphine is not readily available. A report from the Substance Abuse and Mental Health Administration suggests that New Hampshire is not alone, indicating that child welfare agencies “may use a positive toxicology result for methadone or buprenorphine at birth as a presumptive cause for child removal.”
In some states, on the other hand, these cases may not even be reported or investigated. Pennsylvania law requires reporting only if the drug is illegal, although individual hospitals may choose to report other cases. In Massachusetts, for example, the Department of Children and Family Services can screen out a report involving a substance-exposed newborn if the only substance affecting the newborn was methadone, buprenorphine or naltrexone and if the substance was used as part of a treatment program.
But do we know that methadone and buprenorphine are consistent with safe parenting? Unfortunately, there seems to be no research evidence on this question. We do know that with stable dosing, methadone and buphrenorphine does not cause the euphoric “high” associated with heroin and prescription painkillers.
Removing infants from their mothers who are participating in MAT has many negative consequence. It disrupts the critical attachment process between infant and mother. It may lead discouraged mothers to go cold turkey in order to get their children back. This may lead to relapse and permanent loss of the children.
Instead of automatic removal of the children, new mothers on MAT should be supervised by CPS for at least six months to ensure that they are capable of safe parenting. During that period they should receive intensive services akin to those provided by Kentucky’s Sobriety Treatment and Recovery Teams (START), a program that has been in municipalities in New York, Indiana, Georgia and North Carolina. Each family is paired with a specially-trained CPS worker and a mentor who is in long-term recovery. Caseloads are limited and each family receives weekly visits from both the CPS worker and the mentor for the first 60 days. START has been rated as a promising practice by the California Evidence-Based Clearinghouse for Child Welfare.
Most states, particularly those ravaged by the opioid epidemic, are reporting critical shortages of foster homes. Preventing unnecessary foster care placements, in addition to the obvious benefits for parent-child attachment and long-term sobriety of the parent, will allow these homes to be available for children who really need them.
Child Welfare Monitor 
You say new mothers on MAT should be supervised for at least six months. But earlier in the article you state that there is no research to show that MAT is inconsistent with safe parenting. So what, then, is the legal basis for CPS intervening in the mother’s life? After all, the burden rests with CPS to justify its involvement–not with the mother to prove that she is a safe parent. This is a fundamental tenet of our legal system and democracy.
That brings me to another question. Think of all the prescription meds all of us take to address our various health conditions. My guess is there is no/little research on whether those meds are consistent with safe parenting. Shall we subject parents using all those medications to CPS supervision as well?
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Although MAT has been shown to have positive outcomes in the short-term (4 months sober is MINIMAL), where is the research on long-term success, or lack thereof, for MAT mothers and their children? When will children’s quality of life matter in terms of whether or not they should remain with biological parents? The cycle of addiction continues because our system doesn’t seem to be aiming to break the cycle, but rather, is focused on people’s rights as parents and citizens. Children do not have any say in whether they would rather be born addicted to heroin or methadone, but both cause NAS, which is painful for newborns. What about the mother who has had 5 children, all born addicted to substances, has received intensive services each time, yet, continues to get pregnant and birth children who have to experience withdrawl and other major complications related to mother’s drug use, because it is her “right”. I am a foster parent who has seen this happen time and again. These children suffer because “the law” says they are better off with their biological parents. Not always.
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I really appreciate your comment because the whole reason for my blog to show how the system currently emphasizes parents’ rights over children’s safety and well-being. So people who know my work might expect me to come out in favor of removing all newborns with NAS from their mothers. But that is not my position because pregnant women who have enrolled in MAT have shown a desire to address their addiction before their babies are born. We know how to deal with MAT and ease infants’ suffering and the condition seems to be temporary. And there is one more thing: I bet you are a fantastic foster parent who treats the children you foster as your own. But you probably know there are not enough foster parents like you to meet the need. We have to avoid unnecessary removals so that we don’t place kids with the type of bad foster parents that I wrote about in my recent post, which you can find at https://childwelfaremonitor.org/2018/05/29/lets-recognize-that-foster-care-is-a-job-and-pay-accordingly. And I totally agree with you about the addicted mothers who repeatedly get pregnant. I’ve written about that too. To deal with that we need to offer all moms involved with child welfare and drug treatment free immediate access to Long Acting Reversible Contraceptives. See my post at https://childwelfaremonitor.org/2018/04/16/child-abuse-prevention-an-overlooked-approach. Thanks for what you are doing. As a foster parent wannabe, with a husband who refuses to do it, I must be content with mentoring a foster care alum.
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