HD44 - The Perinatal Drug Exposure Task Force

  • Published: 1992
  • Author: Secretary of Health and Human Resources and Secretary of Education
  • Enabling Authority: House Joint Resolution 388 (Regular Session, 1991)

Executive Summary:
For most women, pregnancy is a time of intense joy, pride, anticipation, and excitement. However, for the increasing number of women who use alcohol and other drugs throughout their pregnancies, the birth of a child can be a time of great despair with, too often, a tragic outcome.

Pregnant women who use alcohol and other drugs risk their infants' normal health and development. These substances cross the placenta during pregnancy and can cause a host of adverse effects on the newborn including growth retardation, mental retardation, and developmental disorders. In addition to pregnancy complications, substance abuse increases the risk of poor maternal-infant relationships. The addicted mother typically leads a disorganized, chaotic life which is not at all conducive to providing predictable and positive experiences that newborns require to develop normally.

Addiction to alcohol and/or other illicit drugs is a complicated illness that causes severe problems in every area of life. Seldom does an individual become addicted to a single illicit drug. Most often individuals who abuse illicit substances use them in combination with each other and with alcohol and cigarettes. The problems presented by drug addiction are intensified and compounded when the addict is pregnant. Perinatal addiction exacerbates the usual risks already associated with pregnancy and child birth.

The media has focused significant attention on the problems and challenges of drug-exposed infants. Virginia is not immune to these challenges. The Department of Medical Assistance Services found that 3,248 women screened for high risk pregnancies through the BabyCare Program in 1991 had problems with drug, alcohol, and/or tobacco use. A 1990 study conducted in Florida found drug use among private obstetric patients and those receiving public health services to be about the same. The problem crosses all social and economic groups.

Because of growing concern about the impact of perinatal substance abuse, the 1990 General Assembly created a joint subcommittee to study the problem in Virginia. In 1991, the General Assembly requested (through House Bill 1602 and House Joint Resolution 388) that the Secretary of Health and Human Resources and the Secretary of Education convene a task force to recommend appropriate interagency and interdisciplinary approaches to provide prevention, early intervention, and treatment services for drug-exposed children and their families. The task force was specifically charged with addressing identification of drug-exposed children and their families, hospital discharge planning, the monitoring roles of service providers, interagency collaboration, model programs, data collection, and training needs.

At the outset, the task force adopted a general philosophical approach that laid a framework for later discussions and recommendations. Central to this approach is the belief that the Commonwealth should be sensitive to the complex medical and social issues associated with drug dependency and perinatal drug exposure. Punitive and excessively bureaucratic responses to the problem should be avoided.

The task force affirmed that regular prenatal care plays a dramatic role in effectively reducing the neonatal costs of maternal cocaine use. In one study, estimated neonatal costs for infants born to cocaine-using women without prenatal care exceeded $6,000 while the costs for infants whose cocaine-using mothers had received prenatal care were less than $3,000.

Altogether, the task force's recommendations represent a continuum of intervention and treatment designed to identify substance-abusing women and their children early, link them with appropriate services, collect information about their demographics, needs and the cost of services, and prepare professionals to better address their clients' needs.

The recommendations of the task force follow. They are described in greater detail in corresponding sections of the report.

Identification:

1. Procedures for taking medical histories should specifically include questions about substance abuse. Toxicology tests are not reliable when used solely at birth or in isolation of other detection tools.

2. Health care practitioners should be required to establish protocols that will ensure that they elicit information about drug use while the patients' medical history is being recorded.

3. Professional associations should encourage their members to use appropriate medical history screening processes.

4. When necessary and appropriate, the screening should be followed with a more extensive substance abuse evaluation.

Hospital Discharge Planning:

1. Hospitals should establish protocols for discharging women who are known to have abused drugs during pregnancy and their infants so they will receive referrals for appropriate services.

2. Written discharge plans should be provided to the patients and appropriate professionals who will be involved with the patients' follow-up care.

3. Postpartum, substance-abusing women and their infants should receive priority attention when referrals for services for services are made, and service agencies should pursue all appropriate means to assure the family receives an evaluation and follow-up care.

Monitoring:

1. Follow-up for both substance-abusing mothers and their infants should occur throughout the clinical treatment process as recommended in the discharge plan or any later plan prepared by agencies involved in the treatment program.

2. Follow-up responsibilities should cease when the child is two years old, unless an agency's treatment plan indicates otherwise.

Interagency Collaboration:

During their pregnancies and following their births, substance-abusing mothers may need additional resources in the form of housing, child care, transportation, or other supportive services. Coordination among providers of these services is essential to meet the families' needs as well as to make optimal use of the community services available.

1. Communities should have the autonomy to try different methods of coordinating services and should strive for flexibility.

2. Collaborative interagency efforts should be thoroughly evaluated to provide reliable data on the benefits of programs and the gaps in services.

3. The Community Services Boards should develop protocols to give priority for substance abuse treatment services to pregnant, substance-abusing women.

4. Substance abuse treatment facilities should also be required to develop similar protocols.

5. The Commissioner of Insurance should evaluate both the availability of insurance coverage for substance abuse treatment and recent trends in coverage.

Data Collection:

Collecting data about substance abuse and perinatal drug exposure at the state level is critical for two reasons: policy decisions and resource allocation.

1. The Secretary of Health and Human Resources should designate an agency to serve as a clearinghouse for pertinent data. The agency should prepare an annual report for the Governor and the General Assembly that provides a picture of the problem in Virginia and includes data on the prevalence, costs, and the extent of state and local efforts to address the problem.

2. To collect information on the prevalence of perinatal substance abuse and drug exposure statewide, the confidential portion of the birth and fetal death certificates should be revised to require information about the types of drugs used, the frequency of use, and the source of insurance coverage.

3. Agencies that provide or finance services should modify their data collection systems to improve their ability to gather relevant information.

4. Every service-providing system should monitor treatment costs to evaluate the impact of treatment and the cost benefits.

5. To continue high standards of care, the Virginia Obstetrical and Gynecological Society should encourage the use of standardized antenatal medical records that include a medical history screening tool for determining if patients have used or are using drugs. Medical records that are designed to include this information routinely would greatly assist in identifying and capturing data on substance-abusing women.

Training:

1. Training should be readily available to implement the recommendations for screening, discharge planning, making referrals, and providing services to pregnant, substance-abusing women and their children.

2. Training should be coordinated and incorporated into the variety of existing educational forums.

Recommendations Requiring Legislative Action

Statute

1. Every health care practitioner in Virginia should be required to establish and implement a protocol whereby pregnant women and infants are screened for substance abuse and drug exposure via routine procedures for taking medical histories. The medical history screening should include an assessment of the need for treatment and services.

2. Every hospital should be required to establish and implement a protocol for written discharge plans for both women who are known to have abused substances during pregnancy and their infants so they will be assured of referrals to appropriate services. The discharge planner should discuss the plan with the patient and document referrals.

Resolution

1. Professional health care associations should encourage the use of appropriate procedures for taking medical histories to determine substance abuse among pregnant women. To maintain high standards of care, the Virginia Obstetrical/Gynecological Society should encourage the use of standardized antenatal medical records that include an updated medical history screening instrument for identifying substance-abusing women.

2. Agencies should designate pregnant, substance-abusing women and their children a high priority and should coordinate services and programs accordingly. These agencies should periodically evaluate their efforts to coordinate and collaborate on services for pregnant, substance-abusing women and their children.

3. The Community Services Boards should develop protocols to give priority to pregnant, substance-abusing women for substance abuse treatment services. The Department of Mental Health, Mental Retardation and Substance Abuse Services should develop a model protocol for the community Services Boards and review each Board's protocol to assure that it meets the objective.

4. Every substance abuse treatment facility licensed by the Department of Mental Health, Mental Retardation and Substance Abuse Services should be required to develop protocols to give priority to pregnant, substance-abusing women.

5. Anecdotal evidence suggests that insurance coverage for substance abuse treatment is decreasing dramatically or being eliminated. The Commissioner of Insurance should evaluate both the availability of insurance coverage for substance abuse treatment and recent trends in insurance coverage for substance abuse treatment and report his findings to the legislative subcommittee.

6. The Secretary of Health and Human Resources should designate an agency to be the clearinghouse for data regarding perinatal substance abuse and drug exposure. The responsible agency should prepare an annual report for the Governor and the General Assembly that provides a picture of the problem of perinatal substance abuse and drug exposure in Virginia. The report should include the prevalence, costs, and the extent of state and local efforts to address the problem. Agencies that participate in the development of the report should review the data annually to ensure the most relevant information is being collected. Responsibility for preparing the annual report should cease five years from the date of the initial report unless the General Assembly designates otherwise.

7. The following efforts should be undertaken to improve and expand techniques for collecting data regarding perinatal substance abuse and drug exposure.

• The High Priority Infant Tracking pilot Program (Richmond and Petersburg), administered by the Virginia Department of Health, should include substance abuse treatment for parents as an item for tracking. When the program becomes statewide, referrals for services should be reported to the state health department at the time of enrollment as well as in regular follow-up reports.

• The Virginia Department of Health should explore ways to correlate data from the High Priority Infant Tracking System and VaCARES with the state vital records system.

• The Department of Mental Health, Mental Retardation and Substance Abuse Services should require that community services boards report the number of pregnant women who are receiving substance abuse services. The expanded data collection system should be operational by July 1, 1993.

• The Department of Medical Assistance Services should determine and implement ways to better assess and record the substance abuse treatment needs of participants in the BabyCare Program.

• The Department of Social Services should pursue ways to collect data on:

* the number of child abuse and neglect reports filed that involve substance abuse in the home

* the number of foster care placements due to parental substance abuse

• Every service-providing system should monitor substance abuse treatment costs for pregnant, substance-abusing women to evaluate the impact of treatment and the cost benefits.

8. Training about substance abuse should be more available and accessible.

• Professionals in the fields of health, mental health, social services, education, law, early childhood education and religion should have a basic understanding of substance abuse and its ramifications.

• Private and public agencies at the state and local levels should make appropriate personnel available to conduct and receive substance abuse training, e.g. orientation programs for new employees.

• Graduate school programs for the professions identified above should incorporate into their core curricula basic information about substance abuse, its ramifications, and treatment strategies.

• Regulatory boards that administer licensing and certification exams for health, mental health, and other appropriate professions should incorporate questions about substance abuse into their exams.

• Continuing education programs for the professions identified above should regularly offer units on substance abuse. University continuing education offices should assist in efforts to develop and make available substance abuse training programs.

• Professional associations with members in the professions identified above should offer training about substance abuse to their members.

Budget Amendment

1. Fund additional model programs of interagency collaboration for pregnant, substance-abusing women (e. g., Project LINK).

2. Fund a statewide program to amend the confidential section of the birth and fetal death certificates to collect data regarding maternal drug history and the source of insurance coverage.

3. Fund training programs for health professionals and hospital personnel to assist them in developing and implementing appropriate, effective protocols for substance abuse screening and discharge planning.

4. Fund the enhancement of the Community services Boards' data collection system to collect information on the number of pregnant women who receive substance abuse services.

5. Fund the statewide distribution of a standardized medical record to assist health professionals in assessing substance abuse among their patients and collecting uniform data.

6. Fund perinatal substance abuse resource centers to provide training and technical assistance.

7. Fund substance abuse training programs for professionals in the fields of health, mental health, social services, education, law, child care and early childhood education.

8. Fund outreach programs designed to locate pregnant, substance-abusing women who may need services.