A Letter from the President
2017 Indiana General Assembly
We are at “Half Time” of the Indiana General Assembly. This is the point in the process where bills go through their House of Origin or they die—barring a legislative resurrection of course. Mental health and addiction issues are being viewed as critical to the state and Mental Health America of Indiana is having significant success with its legislative priorities. You can view MHAI priority bills through the link to the bills here.
The Opioid Epidemic is one of the areas of priority of the Governor, the Legislature, and MHAI. There are many aspects to this disease and it must be approached in a multifaceted way, with a focus on prevention and treatment in multiple silos, including mental health and addiction, child services, corrections and housing. You can view bills that MHAI is working in the area of opioid use disorder and other addiction issues by clicking here.
Opioid medications used to relieve pain are beneficial to many, but are often over-prescribed as is now well documented. The overuse and misuse of these medications in the United States over the past decade has contributed to thousands of overdose deaths. According to SAMSHA:
- 7 million Americans reported current non-medical use of prescription drugs in 2010
- 2 million people reported using prescription painkillers non-medically for the first time within the last year—nearly 5,500 a day in 2010
- 1 in 4 people using drugs for first time in 2010 began by using a prescription drug non-medically
- 6 of the top 10 abused substances among high school seniors are prescription drugs.
Most concerning, the opioid epidemic has affected mothers and their newborns as well. In 2013, 11-16% of infants were prenatally exposed to alcohol, tobacco, or drugs. According to the Centers for Disease Control and Prevention (CDC), from 1999 to 2010, yearly prescription opioid overdose deaths among women increased 400 percent over the last 10 years. National data show that from 2000 to 2009, the use of opioids during pregnancy saw a 5-fold increase in hospital births.
Neonatal abstinence syndrome (NAS) is the common term used to represent the pattern of clinical findings typically associated with opioid withdrawal in newborns. Most newborns of mothers who use opioids during pregnancy develop symptoms of NAS, a postnatal drug withdrawal syndrome, primarily caused by maternal opioid use. In 2012, among the neonatal stays with a substance-related condition, approximately 60% were related to neonatal drug withdrawal or NAS. Among maternal stays related to substance abuse, almost one-fourth involved opioids.
Not surprisingly the medical costs of NAS are staggering. A report published in JAMA in 2012, found that the average length of stay for NAS babies nationally in 2009 was 16 days vs. 3 days for all other hospital births and the cost per NAS newborn was $53,400 vs. $9,500. According to this study, 77.6% of these cases were paid for by Medicaid.
According to DCS, 52.2% of Indiana children removed are removed as a result of parental substance abuse. Professionals in the child welfare, judicial, medical and addiction treatment systems generally share significant concerns about women who misuse opioids and newborns with NAS and other problems related to in utero drug exposure. At times, however, the responses of various systems to the needs of these families diverge, resulting in apparent conflicts among treatment practices, medical recommendations, and the policies and oversight provided by courts and child welfare services. Many juvenile courts are often not familiar with Medication Assisted Treatment, and moreover, a recent national survey found that nearly half of drug courts do not use medications in their programs. One of the primary barriers to using medications was reportedly a lack of awareness of or familiarity with medical treatments among professionals outside the treatment system.
This is similar to what was found in Indiana when criminal justice sentencing reform was passed to provide treatment in lieu of incarceration. Connecting the child welfare and juvenile justice system to treatment is similarly critical as it was in connecting treatment to criminal justice under the implementation of HEA 1006.
DCS has the complicated dual role of supporting families while monitoring them and at the same time preventing child maltreatment. DCS has risk and safety assessment policies and practices that are intended to identify immediate safety concerns for children, while evaluating the risk and protective factors of each family. When making decisions about whether to intervene and how to do so in the most supportive manner, staff must take into account the distinctions related to a woman’s pattern of opioid use (and other drug use) and treatment needs. Clearly there is a need for substantial, targeted educational initiatives to increase awareness of the treatment and benefits of MAT in juvenile courts. Again, there is a strong parallel to the situation in HEA 1006 and criminal justice reform.
Treatment of NAS includes non-pharmacological and pharmacological methods. The use of MAT during and after pregnancy is a recommended best practice for the care of women with opioid use. MAT is the use of medications in combination with counseling and behavioral therapies to provide a whole-patient approach to the treatment of substance use disorders. Research shows that a combination of medication and behavioral therapies is most successful for substance use disorder treatment. MAT is clinically driven and focuses on individualized patient care.
The Comprehensive Addiction and Recovery Act (CARA) of 2016, widely hailed as the bipartisan Congressional response to the opioid epidemic, was signed into law on July 22, 2016, and it presents us with a new opportunity. The federal Child Abuse Prevention and Treatment Act of 2010 (CAPTA) already requires CPS agencies to develop a plan of safe care for every infant referred to address the health and substance use disorder treatment needs of the infant. However CARA goes further and requires the plan of safe care to also address the treatment needs of affected family or caregivers and requires states to develop a monitoring system to determine whether and how the local entities are providing referrals to and delivery of appropriate services for the infant and affected family or caregiver. This is a critical recognition of the treatment needs of the mother and the services that must be provided.
In point of fact, a SAMSHA funded intervention plan identified five major time frames when intervention can help reduce the potential harm of substance exposure. These 5 points of intervention are: Pre-pregnancy; Prenatal; Birth; Neonatal; and Throughout childhood and adolescence. A key take-away is that while Prenatal is a critical area of focus, it is one of several opportunities to affect outcomes and the strategies might be different for each. Clearly there is an opportunity at birth to assess the needs of the mother and provide MAT services with DCS support to insure the safety of the newborn as well as other children as well. This treatment may include addiction counseling, detoxification, MAT and residential services.
The treatment of the mother after birth is also a prevention strategy in the case of the potential next birth. According to SAMSHA, the evidence suggests dramatic increases in the prevalence of substance use among mothers with babies under 3 months old based on cross-sectional reports from pregnant, parenting, and nonpregnant women. This increase results from a resumption of substance use following childbirth.
Treatment for the mother at birth and subsequently is critical to the well being of the newborn and other children living in the home. Living with a parent with an untreated substance use disorder can lead to neglect of the child’s basic needs; situations jeopardizing child safety and health (e.g. drug manufacturing and trafficking); severe, inconsistent or inappropriate parental discipline; disruption of parent/child relationship, loss of child’s sense of trust, belonging; separation; and chronic exposure to violence and trauma. Ongoing coordinated services for this population of children and their families throughout childhood and adolescence are critical to a successful treatment regimen.
The Indiana General Assembly is considering several pieces of legislation that would enhance treatment interventions for the mother and baby:
HB 1006, (Kirchhofer, Ziemke, Steuerwald, Shackleford), would insure that DCS makes available when appropriate child welfare substance abuse treatment services that would include addiction counseling, detoxification and Medication Assisted Treatment to mothers in instances of NAS. Training would be made available to Juvenile Court Judges, Public Defenders, and DCS staff. DCS will be able to support the mother and more importantly protect the newborn and other children in the family--all the while enhancing family unity whenever possible and appropriate. Most importantly, Hoosiers could begin to intercept the cycle of addicted moms giving birth to addicted babies. HB 1006 passed the House 96-0 and now moves to the Senate where it will be sponsored by Senators Merritt and Charbonneau.
SB 446 (Merritt, Charbonneau, Breaux,) would refer to the Governor’s Indiana Commission to Combat Drug Abuse the issue of creating an opioid addiction recovery pilot program for pregnant women and women with newborns by providing substance abuse and addiction treatment in a residential care facility as well as home visitation services in three locations around the state. SB 446 passed 48-0 and now moves to the House where it will be sponsored by Representatives Kirchhofer and Davisson.
SB 243 (Crider, Charbonneau, Ruckelshaus, Breaux, Head, Randolph, Tallian) would refer to the Governor’s Indiana Commission to Combat Drug Abuse the issue of creating a maternal neonatal opioid addiction pilot project to provide healthcare system resources needed for opioid addiction treatment and recovery for NAS mothers and their newborn children. SB 243 passed 46-1 and now moves to the House where it will be sponsored by Representative Kirchhofer.
Communities are often unprepared to provide services to the large number of pregnant women who misuse prescription medications and heroin, and they are calling for an organized and coordinated response. Without a comprehensive collaborative response that includes child welfare, healthcare and substance abuse treatment, and mental health professionals, families are not well served. Cross-system initiatives lead to better results by facilitating better communication, clearly defining the roles of the various professionals who serve these families, and maximizing the resources of multiple stakeholders who have a vested interest in accomplishing shared goals.