This is the story of a young woman with a 15-year history of severe opioid use disorder (OUD), intermittent hospitalization, and incarceration, who becomes pregnant. She has a history of trauma and mental health issues, and few social supports. Her story is the subject of a case report recently published in the Journal of Addiction Medicine.
It’s well known that methadone, in adequate doses, helps to keep pregnant women in treatment and reduces the risks of illicit drug use and overdose. Across the country, some—but not all—corrections facilities will continue pregnant women on opioid agonist treatment. Overall, most correction facilities fail to follow evidence-based treatment guidelines for OUD.
When people with OUD are incarcerated, “methadone is generally stopped immediately—without a taper,” Jessica Gray, MD, lead author on the report, told AT Forum. “Opioid agonists are life-saving treatments that shouldn’t be withheld or limited when people are incarcerated, but outside of Rhode Island and a few other facilities, like Rikers, that’s not the case,” she added. Even jails that do provide methadone treatment for pregnant women generally fail to continue methadone when women return to jail after giving birth, according to Dr. Gray, who works at Massachusetts General Hospital and completed a fellowship in addiction medicine at Boston Medical Center.
The Patient’s Early History
The patient began using illicit medications at age 13 to self-medicate anxiety and depression. She attended a methadone program sporadically. While hospitalized for a benzodiazepine and opioid overdose, she learned that she was pregnant.
The months that followed were marked by repeated emergency department visits, hospitalizations, and incarcerations. The patient failed to return for prenatal care, despite follow-up appointments and outreach calls.
- Emergency department visits: 6+
- Hospitalizations: 3
- Incarcerations: 3
- Prenatal visit: 1 (while incarcerated)
She had bouts of sedation, probably due to the effects of “methadone treatment combined with illicit benzodiazepines, gabapentin, and clonidine,” the authors of the study believe. She also had pneumonia, a urinary tract infection, a broken arm (from falling), abdominal trauma (after an assault), a potentially life-threatening kidney infection, and a weeklong hospital stay related to abnormalities seen on the baby’s heart monitor. And she was HCV-positive, with a high viral load, indicating an infection that she could pass on to her baby.
According to a study by Kelsey and associates, examining national jail policies in the U.S:
- 69% of women admitted to local jails meet recognized diagnostic criteria for substance use disorder (previously termed substance abuse or dependence)
- About 6% to 10% of women in jails are pregnant
- Almost half of all pregnant women with OUD in U.S. jails went through withdrawal without the help of opioid agonists or similar medication
This patient was one of the lucky pregnant women whose methadone treatment was continued per protocol while she was in jail.
The patient was in jail and at term when labor began. She was taken to the hospital to have her baby. Her shackles were removed, but she was barred from contacting someone to be with her during labor. A corrections officer was posted in the hall outside her hospital room. As distressing as this sounds, Dr. Gray told AT Forum that some institutions still keep women shackled or restrained during labor, with a guard posted inside the room.
Because the woman was incarcerated when she gave birth, the newborn was taken away, and the mother’s custody rights were immediately suspended.
The infant, a son, was healthy and born at term—despite the mother’s lack of prenatal care, and her intermittent use of illicit substances during pregnancy. This was likely thanks in part to her continued treatment with methadone throughout her pregnancy.
Standard care at the woman’s jail is to abruptly stop methadone treatment after a woman gives birth, but the patient’s team—the authors of the study—convinced jail authorities that this would increase the patient’s risks of overdose and relapse post-release. So her methadone treatment continued in jail during the months postpartum, and eventually she was released from incarceration
Jails and OTPs in Alliance
Clearly, a need exists for jails and OTPs to work together to help women like this patient. But how to facilitate it?
According to Kevin Fiscella, MD, MPH, a board member of the National Commission on Correctional Healthcare (NCCHC), some jails have OTP licenses in place, but most need to partner with a community OTP.
Partnering is easier than it sounds, because usually a relationship already exists, Dr. Fiscella told AT Forum. “People come into a jail already taking methadone or buprenorphine, prescribed by an OTP, and the jail personnel need to know the dose.”
Dosing information and the dosing history are especially important for pregnant prisoners. As the pregnancy progresses, women may need higher doses in order to prevent withdrawal. So OTPs want jails to have the dosing information. They, and the jails, want treatment to continue, to protect not only pregnant patients, but all patients from the risks of overdosing once they leave jail.
This collaborative relationship isn’t difficult to establish, but it’s not very common—creating an opportunity for jails to expand their relationships with community OTPs, thus improving care.
The Silo Effect
The situation Dr. Fiscella described works well, but achieving it isn’t always without problems.
Dr. Gray described the treatment system for patients with OUDs as “broken” in some ways, and operating “in silos” that limit interactions. “OTPs are heavily regulated, not part of the mainstream health system or community organizations,” she explained. “Our corrections system is another silo. The more we can get out of these silos and engage our community partners and collaborate as teams the better we can understand complex treatment issues.”
The relationship can be developed either in a crisis, or ahead of time—so people know they can rely on the other entity, the OTP or the hospital, in the future.
“Understanding the safety, logistical, or other concerns and needs of the systems you work with is critical. Working across organizations to address those issues can improve the experience and comfort of all parties, such as in this case providing education and support to nursing staff around methadone in the jail.” You need to support each other, she added, pointing to the current case as a good example of what collaboration can do.
We asked Dr. Gray what OTP personnel can do to help other women facing these challenges. Are counselors—or management—most effective in communicating with jails?
Both, Dr. Gray said, for she sees a role for individuals and groups at all OTP levels. Members of a multidisciplinary team can choose the person best suited to present the message to the house of correction, but everyone can impact change. The idea is to create formal and informal partnerships, and make those relationships work—even before a crisis exists.
One Patient Can Make a Difference
“Advocacy can start on an individual level”, said Dr. Gray, “and in this case was used to change the local landscape for women with opioid use disorder who deliver in jail.” The Case Report patient transitioned from being at an incredibly high risk for a bad outcome, to turning her life around.
Dr. Gray later met another pregnant woman in similar circumstances—a woman who wasn’t afraid of what she faced, because of the team’s groundwork with the woman in the Case Report. Dr. Gray was deeply moved to have made such an impact. “The hope is that the precedent you set in providing evidence-based treatment behind bars will positively impact the treatment of future incarcerated patients.”
A Remarkable Change
The new mother discussed earlier in the Case Report underwent a remarkable change after giving birth, Dr. Gray told AT Forum.
There’s no way to know if the change will be permanent, but Dr. Gray is optimistic. “The more that evidence-based treatments (such as opioid agonist medications) are provided, the more likely our patients will survive long enough to be successful.”
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Gray J, Saia K, Walley AY. Case Report: 28-year-old woman with opioid use disorder delivers healthy baby while in custody: Addressing Forced Detox. J Addict Med. October 30, 2018. doi:10.1097/ADM.0000000000000468.
Kelsey CM, Medel N, Mullins C, et al. An examination of care practices of pregnant women incarcerated in jail facilities in the United States. Matern Child Health J. 2017;21:1260–1266. doi.org/10.1007/s10995-016-2224-5.
American Society of Addiction Medicine: The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. KM Kampman. 2015. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf.