In 2006, Daisy Goodman first experienced a patient disclosing a narcotics addiction. A certified nurse midwife working in obstetrics, Goodman had had years of experience working with pregnant mothers to cultivate a healthy pregnancy and birth. But this was her first mother on opioids. More revealing than the patient’s disclosure, however, was her approach toward it.
Citing her own internet search on opioid addiction and pregnancy, the patient requested treatment with methadone and said that she would drive the 2.5 hours from rural central Maine to the nearest methadone clinic. And so she did. For the entirety of her pregnancy, she drove five hours every day to receive her dose of methadone and return home. This patient helped Goodman appreciate “the incredible risks and inconveniences to themselves [women make] to prevent harm to their pregnancies.” Acknowledging that women of childbearing age are the fastest growing demographic afflicted by opioid addiction, Goodman decided to devote her career to improving access to treatment and outcomes for these women. Goodman, who has since received a doctorate in nursing practice and a master’s in public health, now works in Dartmouth-Hitchcock’s Department of Obstetrics and Gynecology, where she is one of the leaders of Dartmouth’s perinatal addiction program.
Almost all pregnant women addicted to opioids develop opioid use disorder (OUD) prior to pregnancy. Many become dependent on opioids after chronic prescription use of narcotics, similar to the other victims of the opioid crisis. Dr. Alison Holmes, a pediatric hospitalist at Dartmouth-Hitchcock, likes to underscore that “the vast majority of these women are in treatment … they’re doing everything they are supposed to be doing,” receiving methadone or buprenorphine and often additional counseling or support. Additionally, she urges clinicians and the general public to consider the biopsychosocial factors that lead to addiction. “Most of the women who end up with addiction are trying to suppress some sort of pain. Most have some sort of trauma history. Much of it comes from multigenerational trauma that comes from having lived in poverty.” She gets frustrated with her colleagues who pass judgment on these mothers and thus compromise care of mother and baby: “The minute that you give a subliminal message that ‘you’re not wanted here’ or that ‘I think you did something that harmed your baby,’ you’re going to totally undercut the ability for them to room in and stay with the baby.”
Goodman supports the practice of a holistic obstetric assessment: “Too often, we [obstetrics practitioners] have managed pregnancy in isolation from the rest of the patient’s life. In actuality, a pregnant woman’s pregnancy is affected very strongly by everything that came before it. Food insecurity, housing insecurity, untreated mental health conditions … What we need to do … is have the initial assessment be 360 degrees — to screen for domestic violence, history of trauma, food insecurity, transportation, whether or not they have heat in the winter, veteran status, et cetera.”
She also highlights the psychological struggle that addicted mothers face. “Women with OUD who become pregnant suffer extreme dissonance about their desire not to use anything that could be harmful to the baby — and they’re very concerned about withdrawal for the newborn, and they’re very concerned about the potential toxicity of opiates … but they also are very concerned about the social implications, for example, the involvement of child protective services… they suffer extreme self-blame and guilt during pregnancy.” One benefit of this concern is that it often serves as the impetus for treatment. As Goodman has observed, “It is an extremely motivational time for women to seek treatment … Pregnancy and parenting are lifesavers for many women.”
Dartmouth’s solution to combatting perinatal addiction begins in the obstetrician’s office. Through Goodman’s training and research, she worked with her department to implement a confidential tablet-based screening tool for every patient that is administered in both the first and third trimesters of pregnancy. The first step screens for past alcohol and illicit drug use. A positive result leads to an enhanced set of screening questions about current alcohol or drug use. A nurse follows up on all positive screens and shares the results with the provider. After a brief intervention with the provider, the patient may choose from a menu of treatment options. Most of these patients elect to participate in Dartmouth’s perinatal addiction program, in which patients with OUDs make up the majority. Dr. Holmes praises the program for its interprofessional approach, with collaboration between physicians in obstetrics and pediatrics, nurse practitioners, nurses, nurse midwives, social workers, care coordinators, lactation specialists and others.
The perinatal addiction program is called Moms in Recovery (MORE), a collaborative initiative of the Departments of Obstetrics and Gynecology, Psychiatry and Pediatrics. Dr. Julia Frew, a Dartmouth-Hitchcock psychiatrist who specializes in reproductive and perinatal psychiatry, serves as Medical Director. While buprenorphine management is a major part of the program, over two-thirds of the women experience some level of psychiatric symptoms, and many others struggle with comorbid addictions. Dr. Frew says that the team also “tries to help with everything that we can.” The program offers individual and group addiction therapy, in addition to a number of community resources that address the holistic nature of substance use and pregnancy. The Upper Valley Haven, a homeless shelter, helps women find stable housing, and WISE, a domestic and sexual violence advocacy group, offers support and education to women struggling with unhealthy relationships. Throughout the four years the program has been in place, it has evolved tremendously to meet the needs of the women. The program now offers childcare support, an on-site food pantry and healthy foods for sessions, a diaper bank, donated baby items, a recovery coach, case management services and a pediatrician who comes in monthly to do well-child checkups and administer immunizations for the mothers and their children. Dr. Frew says that the patient-centered approach to care allows for the women to support and encourage each other.
In the epicenter of the opioid crisis, Dartmouth-Hitchcock’s perinatal addiction program offers a beacon of hope, of recovery, of change for mothers suffering from addiction. The resoundingly clear message from Daisy Goodman, Alison Holmes and Julia Frew are that, with the help of buprenorphine, counseling and a holistic support network, mothers addicted to opioids can give birth to healthy children and go on to leading a healthier life. In Dr. Frew’s words, “It’s extremely fun and rewarding work … We really see these women stabilize and get better. We can turn things around.”
Editor’s Note: This is the first piece in a two-part series. Please read the second piece here.