AAP Voices Blog

You’re making well-baby rounds in the nursery, where the urine toxicology results for one of your young patients came back positive for opioids. Or maybe it’s a newborn’s very first outpatient primary care visit, and you see in the hospital discharge summary mention of maternal methadone use.

What’s your gut reaction? What thoughts are starting to pop into your head? Does your perception of this mom-baby dyad suddenly shift? Do you realize you’re thinking about them differently? Are you surprised because you did not expect that kind of history from the mom, or do you feel a sense of frustrated inevitability that this mom is on her way towards having yet another child taken away from her?

As physicians, every time we enter a patient room, we are forming impressions. Expectations and appraisals have begun weaving their way unintentionally through our minds. Why are we having these thoughts? Are we reminded of prior patients and families? Attention-grabbing headlines we’ve seen in the news?

Regardless of where they’re coming from, we have to pause, acknowledge, and reflect upon these thoughts and feelings. Our implicit biases are going to shape our interactions with patients and families – not only through our language, but our non-verbal communication. Our patients and families can sense how we feel, how we react to them. They are going to pick up on our judgment, and moms with a history of substance use may have already faced a great deal of stigma long before they meet us.

Recognizing, questioning, and reframing initial impressions and judgements

Once we have recognized potentially problematic reactions, can we shift them? Instead of immediately assigning labels and expectations based on our gut feelings, can we think through the why and how behind the situation?

We are asked to do this all the time in medicine for a myriad of conditions. Instead of lamenting about our “non-compliant diabetic,” we try to ascertain the story behind why this person is struggling to control their diabetes. Maybe it’s because of housing instability, and the patient doesn’t have access to a refrigerator or cool place to store her insulin. Maybe this adolescent is frustrated with being medicalized and just wants to be able to go out for ice cream with his friends without dealing with insulin.

Similarly, if this mom in front of you is using opioids, alcohol, or other substances, and is not engaged in addiction treatment, can we think about why that might be, instead of immediately assigning blame? We have no idea how she came to this place in her illness. We don’t know how this is affecting every part of her life and self.

Maybe she’s only ever been confronted with disrespect and disgust due to her substance use, making her wary of medical care and providers with negative attitudes. Maybe she wanted to start treatment but was fearful that it may result in removal of her child or charges for prenatal substance use. Maybe no doctor has ever sat down and engaged in a real conversation with her about her substance use, recommending and offering to assist her in getting treatment. Or maybe there’s not readily available treatment for pregnant women anywhere nearby. Whatever the reason for her substance use, addiction is a brain disease and so she may be using just to try to feel normal and not be sick from withdrawal. This disease – not a choice or moral failing – is driving the situation.

“Our patients and families can sense how we feel, how we react to them. They are going to pick up on our judgment, and moms with a history of substance use may have already faced a great deal of stigma long before they meet us.”

Supporting Evidence-Based Treatment Options

So, what if the mother we’re seeing is actually already in treatment, such as a methadone program? That means she’s already made an often difficult decision, despite knowing it will result in judgment and discrimination against her and likely a social services report for her baby. She’s facing these risks in an effort to save her own life and give her baby the best life possible. We have a responsibility as physicians to understand addiction treatment and its evidence base: that medications such as methadone and buprenorphine are highly effective, not only in reducing the risk of death and overdose but also improving the likelihood of a healthy pregnancy.

We all need to understand that taking these medications is not substituting one addiction for another – it is the cornerstone of effective treatment. Major medical societies such as the AAP and ACOG are in agreement: pregnant women with opioid use disorder should receive medication as a crucial component of multifaceted care that also includes counseling and community support services.

Connecting on Common Ground

Once we have examined our own internal biases, and tried to shift our thinking, we can move forward and build a collaborative relationship by connecting on common ground. We need to understand that addiction doesn’t discriminate. People with a substance use disorder don’t fit a certain profile. As pediatricians, we want to provide the best possible medical care for the child. Similarly, this mother cares about her child, whether or not she is using substances. No woman is using substances to hurt her baby. We are in this situation together, all working towards a common goal. We need to communicate with empathy and unite with the family. We should not pit baby against mom, or mom against baby. We need to show that we are on the side of the family – baby and mom – by offering assistance, access to care, and support for treatment.

We may not have much control over what happens once a mandatory report goes out to social services, but we can show that we care about what happens to both mom and baby. We can be supporting parents through this process and connecting them with helpful resources, instead of being seen as trying to take away the baby.

Our duty as pediatricians extends beyond the child to the families in which our patients live. We need to be educated about addiction and other co-occurring maternal mental health issues. We must know the science behind effective treatment, and be familiar with the logistics of how to assist pregnant women and mothers in overcoming barriers to accessing evidence-based treatment. Then as pediatricians we can truly be advocates, helping moms access addiction treatment for the very first time or being the cheerleader in their continued treatment and recovery.