Sunday, March 22, 2009

No privacy for pregnant mothers in an American community hospital?

As the head of obstetrical services at our hospital, I was sitting in a meeting one day when the idea was broached that local obstetricians should routinely perform drug screening on the urine of all pregnant women. We were told that at a community hospital such as ours, 15–20% of women would test positive for illicit drugs. At present, the obstetrical service at our institution identifies drug use in only about 5% of our patient population. Therefore, we must be missing quite a few cases that could be identified by routine maternal drug screening. Furthermore, the hospital down the road was preparing to initiate such a plan. We must, after all, keep up with the competition.

At this point in the meeting, the role of government was introduced. It was suggested that an even better plan would be for our state (Tennessee) to mandate routine maternal drug screening. This, naturally, would mean one more state-sponsored loss of dignity for all expectant mothers. And for some, the effects would be more far reaching. Once women were identified by a positive urine drug screen, the results would go to the appropriate state social service agency. Big Brother, or rather Big Sister, would then come knocking on the door for the euphemistically named “home visit.” The mother would be encouraged to mend her ways. Of course, if she did not mend her ways in a manner satisfactory to the state, her children could be removed and sent to foster care.

Maternal drug use in pregnancy creates many problems for both the infant and mother. In relation to expectant mothers, such terms as “drug problem,” “drug addiction,” and “drug abuse” have much more serious meanings than they may have for other people. Maternal cocaine use in particular results in a wide range of morbidities — low birth weight infants (infants weighing less than 2,500 grams or five and a half pounds), infants admitted to intensive care units, and infant mortality. Amphetamine is probably the next worst drug for expectant mothers, causing many of the same types of problems as cocaine, though on a somewhat reduced scale. Maternal opioid use is most commonly associated with infant withdrawal syndrome. While it is rarely lethal, it is emotionally troubling to those who witness an infant coping with this unjust inheritance. Marijuana, while not as damaging as the other drugs, has been shown to result in smaller infants with smaller head circumferences.

It might be surprising to learn that the majority of infants born to drug-using mothers actually do fairly well. One of the best determinates of neonatal health is whether the newly born infant is admitted to the neonatal intensive care unit (NICU) instead of the regular well-baby nursery. A study from the Minneapolis-St. Paul area looked at the number of NICU admissions among women who tested positive for illicit drugs (cocaine, opioids, and marijuana). This number was then compared to the remainder of mothers, who had negative tests. The results were a 20.7% NICU admission rate for mothers who were drug-test positive versus a 12.3% NICU admission rate for mothers who tested negative. One can argue whether this glass is half full or half empty. Maternal drug use resulted in a 69.7% increase in admissions to the intensive care unit. However, 79.3% of infants born to women who used drugs were admitted to the regular well-baby nursery. Perhaps the best way to look at the data is to say that maternal drug use conferred an additional 8.4% risk of bad outcomes beyond the baseline rate. In considering this drug-induced penalty, one should also note that many babies who are initially admitted to the NICU eventually have a good outcome.

Reduction of the 8.4% increase in infant morbidity among drug-exposed children is a worthy goal. Since drug-abusing mothers often lie about their habits, routine universal drug screening has been increasingly advocated. Routine urine drug screening is often touted as highly accurate and inexpensive. Once women are identified as users of illicit drugs, they can be directed towards comprehensive programs. These programs, which concentrate on drug abstinence counseling and obstetrical care, have shown progress in lessening infant morbidity. While this certainly sounds good, it can be shown that each of the premises is highly problematic.

First, maternal drug testing is not the only way to identify substance abuse. While it is true that over 50% of women who abuse drugs will not admit to doing so, there are other ways of identifying most drug-abusing women. Think of it as a type of profiling.

Several studies have shown that carefully designed questionnaires identify the majority of drug-abusing mothers. In one study from the University of California, Davis, 93% of women whose urine tested positive for drugs had one of the following three characteristics: actual admission of drug use, poor or no prenatal care, and cigarette smoking. By asking the right questions and noting salient patient characteristics, one could identify the women most likely to be using drugs.

Secondly, routine drug screening is neither straightforward nor cheap. Abstaining from cocaine and opioids for a 72-hour period prior to testing often leads to a negative drug test; consequently there is ample opportunity to beat the system. In addition, some drugs, such as amphetamines, have a high false-positive rate; i.e., the urine tests positive even when no amphetamines have been taken. Confirmatory testing with gas and liquid chromaphotography is necessary to confirm a positive drug screen. This sounds expensive, and it is. As an example, the average charge to our office for routine prenatal blood work is $77. The charge for urine drug screening is $19. But adding a confirmatory test for a positive drug screen costs another $70. By this measurement, the cost of drug screening plus confirmation exceeds the cost of routine prenatal lab work.

The most problematic idea, however, is the notion that once drug-using mothers are identified, they can be counseled, supported, and nurtured to the betterment of themselves and their infants. Several studies have been undertaken of this noble cause. The best one, perhaps, is from Brown University, and was published in 2000. This study also showed the most encouraging results. Eighty-seven women were recruited over a three and a half year period. They received extensive support from Project Link, an organization that offers patients individualized therapy, including group and individual psychotherapy, nutritional advice, home visits, and transportation services. The 87-member study group was compared to a control group of 87 substance-abusing women who received the same care but after delivery. Compared to the control group, the study group showed a reduction in the number of premature infants, low birth weight infants, and infant admissions to the intensive care unit.

This appears to provide encouragement, but a closer look at the numbers is more sobering. The obstetrical service involved in the study was delivering approximately 9,000 babies per year. If we assume a 15% rate of maternal substance abuse, the 87 women enrolled in this study represent less than 2% of the substance-abusing women delivering at the hospital. The authors also stated that each of the women in the study group self-reported their addiction and volunteered for the program. This is clearly an unusually dedicated group of women who wanted to do the best for their infants. Unfortunately, it is also a small group of women. The vast majority of substance-abusing mothers would not comply with such a program. The noncompliant mothers were aware that their behavior was harmful to their babies, yet their addiction to the drug was just too strong. Inchoately, they know what the apostle Paul knew: “I do not understand what I do. For what I want to do I do not do, but what I hate I do” (Romans 7:15). No matter how good the intentions of large hospital systems and state government, these entities cannot loosen the grip that addicting drugs have on a mother.

Of course, there is one option for drug-abusing mothers that might prove successful. In a study done through the North Carolina state penal system, pregnant inmates were followed closely throughout their gestations. Their prison-based pregnancies were compared to their other pregnancies. Specifically, infants who were delivered when their mothers were in prison were compared to their siblings, delivered when their mothers were not in prison. Pregnancies that came to term in prison resulted in the birth of larger infants with fewer premature deliveries. It was speculated that the women received more regular prenatal care and better nutrition while in prison. Also, they presumably had forced abstinence from drugs. Still, the authors of this study concluded that the benefits of slightly larger babies were overridden by problems inherent to incarceration, such as familial separation and maternal anxiety. Mercifully, there are no serious voices suggesting this level of governmental intervention.

A final argument is that routine drug screening in pregnant women might keep them from seeking prenatal care. In researching this paper, I identified no studies that quantitated the effect that routine maternal drug screening would have on attendance for prenatal care. It is a well-accepted fact that under the current system, where drug testing is usually not mandated, drug-abusing women show up less often and more sporadically for prenatal care. There is reasonable concern that mandatory drug testing, and the resultant governmental demands for drug abstinence, would still further decrease attendance at obstetrical clinics.

There is, to be sure, a fairly sizable group of women who will not commit to drug abstinence but still show up for prenatal care. Many of these women attend methadone clinics. Methadone can best be viewed as opiate-lite. It should not be viewed as a treatment for all drug-abusing women as it is only prescribed for women with opiate addictions. (Opiates include such well-known drugs as heroin, morphine, oxycodone and hydrocodone.) As an example, methadone would have little benefit for a woman with a crack cocaine problem. In general, however, methadone does seem to have three distinctive advantages over illicitly obtained opiates. First, there seems to be less morbidity for the newborn infant. Second, a user of methadone is less likely to need escalating doses of the medication to get the desired calming effect. Third, withdrawal from methadone is somewhat easier than with other opiates.

But probably the greatest good derived from methadone prescription is that it tends to keep pregnant women within the prenatal care system. There is much evidence to show that women who both receive methadone in a controlled manner and also receive enhanced prenatal care have superior outcomes to women who get their opiates off the street. The prenatal care focuses on fetal growth, which can be followed fairly reliably with ultrasound measurements. It is a general truth that babies who grow well in the womb do well in the nursery. For fetuses who do not grow well, enhanced fetal surveillance is performed. This sometimes allows the delivery of infants prior to the development of fetal compromise.

In my opinion, the way in which we care for mothers who receive methadone should be a model for how we should treat all women at high risk for drug abuse. Pregnant women should be carefully questioned at the beginning of their prenatal care. Women deemed to be at high risk for drug abuse should receive the same type of prenatal care as pregnant women who are taking methadone. The growth of their fetuses should be monitored closely with ultrasound measurements. For infants who do not grow well, more intensive testing and occasionally early delivery should be offered.

This article has outlined two basic arguments against routine maternal drug screening. One is based on human nature. The other is more pragmatic. From a practical standpoint, a positive drug screen is not a secret between a patient and her physician. The test results are routinely reported to hospital social service workers who in turn report them to the appropriate state agency. The more intrusive the state becomes in monitoring drug-using women, the more each allegation of drug use will be challenged. Routine drug testing would invariably result in expensive retesting and confirmatory testing; it would therefore lead to thousands of bitter and costly legal contests. It would also lead many women who need prenatal care to decide not to get it, for fear of the tests and consequent legal involvements.

A drug-abusing woman who discovers that she is pregnant is heavily conflicted. There is the desire to do what is the best for her baby, but there is also the pull of a strong addiction. Only a few, highly motivated, strong-willed individuals are likely to benefit from comprehensive drug abstinence programs. Such women are not waiting to be notified by a hospital or state agency that they have a problem and need help. They sign up without such prompting. But for women who are either untruthful about their drug use or unwilling to commit to drug abstinence, it is unlikely that being notified of a positive drug test will materially change their behavior, unless they are in fact imprisoned.

As mentioned previously, there is an 8.4% increase in intensive-care admissions for infants born to drug-abusing mothers (20.7% versus 12.3%, for women who are not involved with drugs). While this number is not high enough to warrant extraordinary measures (e.g., incarceration) in order to protect the fetus, it is high enough to make some recommendations for closer concern and careful medical monitoring — not for a large, new extension of state power, fraught with its own possibilities of abuse.


End this postcode lottery in British cancer care

The nightmare of NHS bureaucracy needs sorting out

Every person reading this article has a one in three chance of getting cancer. In the most recent year for which there are statistics, 367,000 men and women in England had cancer diagnosed.

The NHS Cancer Plan for England was published in September 2000 with the laudable ambition of reducing cancer deaths. Investment was planned to improve survival through prevention, screening, early diagnosis, better treatment, hospices and cancer networks. Investment in the NHS has risen from 4.8 per cent of GDP in 1997 to 9 per cent today.

Has this money achieved its aims? Partly. Fewer people smoke, more are screened and waiting times are shorter. But bureaucracy has been an obstacle to greater success. The National Institute for Health and Clinical Excellence (NICE) has prevented effective treatment becoming widely available; the weaving of a spider's web of administrative muddle has led to death and misery.

There remains a wide variation in the standard of care and the chances of survival. This is partly because the Government believes in local autonomy - 150 primary care trusts dictate local policy, creating a postcode lottery. Living in Richmond means that you might be prescribed a drug for cancer, while you cannot be effectively treated in the stinking black hole that is Oxford. The annual administrative budget for these trusts is £5 billion.

One of my colleagues has shown that death rates from kidney cancer are solely determined by postcode. In areas where the trusts allow the use of a particularly effective drug the average survival rate is more than two years; in those where it is refused, average survival time is six months. Many readers will know that NICE has changed its mind three times over whether these kidney cancer drugs should be available.

In 2000 the Secretary of State for Health wrote in his introduction to the Cancer Plan that “decades of under-investment alongside outdated practices mean that survival rates lag behind the rest of Europe... too many variations in the quality of care across the country leave patients frustrated by the postcode lottery.” His view is still correct. Presumably his successor now needs a hearing aid as those words ring in his ears.

Secretary of State, please could our wonderful NHS be granted the gift of sanity in prescribing and clarity in administration? The nightmare of bureaucracy needs sorting out. The rationalisation of NICE and the primary care trusts would free up funds that could be used to benefit patients.


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