Should Pregnant Women Be Allowed To Use Opioids Under Medical Supervision?

When Sara learned she was pregnant two years ago, she simply assumed her baby would die. She was a sex worker and active drug user at the time, shooting both cocaine and heroin, and the news came at a Baltimore hospital where she’d landed after being beaten and robbed in the city. Medical staff tended her wounds and informed her that she was one month along.

Her doctor ordered her to stop using cocaine, but warned that if she tried to wean herself off heroin, she would likely miscarry or deliver the baby prematurely. Withdrawals from opioids can cause devastating contractions in pregnant women, which can put the mother and the child at greater risk than the drug itself. In the United States, health care professionals typically advise women in this situation to seek counseling and medication-assisted treatment to ease the transition. But lack of access, stigma regarding their drug use, or fear that their children will be taken away, often keep them away from the health care system until they go into labor.

It’s an increasingly familiar problem — not just in the U.S., but around the globe. While the opioid crisis and its attending pathologies have become well-known to many Americans, the World Health Organization estimates that as many as 13.5 million people across the world use one variety of opioid or another — including 9.2 million who, like Sara, use heroin. (To protect her identity, Sara’s full name is not being used.)

Pregnant women make up a small portion of illicit drug users overall — between 2012 and 2013, it was estimated to be only 5.4 percent in the U.S. But that represents an increase from the previous decade, with incidences of neonatal abstinence syndrome, where infants are exposed to opiate drugs in the womb, quadrupling between 2003 and 2012.

Despite all this, specialized drug treatment for pregnant women is uncommon, with the World Health Organization estimating that as few as 21 countries provide such services. “[T]he main obstacles include a lack of childcare services and judgmental attitudes to women who abuse drugs, especially if they are pregnant,” according a 2016 report from the International Narcotics Control Board.

This is something that one doctor in Australia, where heroin use is on the rise, is angling to change — with an unconventional, even contentious solution: Let pregnant women shoot up under medical supervision. As medical director of the Medically Supervised Injecting Center in Sydney, Dr. Marianne Jauncey wants to help at-risk mothers freely use opioids under the careful observation of a nurse, at a facility known as a supervised injection site.

Such facilities, which provide sterile syringes and stainless steel cubicles where drug users can mainline black market narcotics, have existed for decades, and the research behind them strongly suggests they are a kind of “safe haven” that limits the spread of HIV and hepatitis C and reduces overdose deaths. They also don’t encourage crime or drug use — generally, the people who use supervised injection sites are homeless, unemployed, suffering from trauma, and are already established drug users. If an overdose occurs, nurses are on hand to immediately administer oxygen and naloxone, an opioid overdose antidote. And to the best of anyone’s knowledge, there has never been a recorded death from an overdose at a supervised injection site.

There are at least 100 such facilities operating around the world, mostly in Europe and Canada, though the idea has proved unpopular with American lawmakers. (Seattle announced plans for the nation’s first such facility earlier this year.)

Jauncey, who has led Australia’s only facility for nearly a decade, recently found herself at the center of a fierce debate when she suggested last year that the facility expand its services to include 16-year-olds and pregnant women. Troy Grant, then the Deputy Premier of New South Wales, described Jauncey and her colleagues as “off their rockers,” and called the proposition “ridiculous,” according to The Daily Telegraph.

Some experts in the U.S. have voiced similar concerns. “The first policy physicians and other medical care providers should follow is, ‘Do No Harm,’” says Dr. Indra Cidambi, vice president of the New Jersey Society of Addiction Medicine. “Supervised injection sites provide individuals addicted to drugs a safe place to continue using, but with monitoring overdose. This is contrary to the ‘do no harm policy’ because it sends the message that it is OK to continue using drugs despite negative consequences to the individual and the unborn child.”

Jauncey emphasizes that she does not approve of or condone drug use, especially in pregnant women. “But we have to be pragmatic and deal with the situation in front of us,” she says.

While her stance may sound counterintuitive, she has the support of medical specialists, including the Royal Australian and New Zealand College of Obstetricians and Gynecologists. And in fact, Australia is one of the few nations that ban pregnant women from supervised injection facilities. (Denmark does as well.)

Though far from ideal, a visit to a supervised injection site may be the first point of engagement for getting a pregnant woman the care she needs, supporters of the practice argue. And the sooner she can be engaged, Jauncey says, the better outcomes will be for both mother and the unborn. That engagement window typically comes after the woman has used drugs at the site, when they aren’t feeling stressed or in withdrawal.

“The lesser of two evils is, see if we can attempt engagement,” Jauncey explains. “If we can’t, she comes in, where she does use, and we are there. If anything happens, we are immediately able to intervene and protect her and that baby. And what we also know from 16 and a half years of experience and more than a million injections is that our success at engagement and connection generally happens after the drug injecting has been allowed to occur.”

Jauncey’s position is supported by Mary Ellen Harrod, CEO of New South Wales Users and AIDS Association, who herself was using heroin while pregnant in the 1980s. She says access to a supervised injection site would have helped her.

“If you give people support at the right time — and that’s really what this whole argument is about — this is a way to support women who are clearly in trouble,” Harrod says. “If you’re using a safe injecting center and you’re pregnant, you probably really do need non-judgmental support. It’s by far the best option for everyone concerned, including the social welfare and health cost.”

These ideas have been readily embraced in other parts of the world — particularly in Canada, where at least 11 supervised injection facilities opened with renewable licenses this year alone, joining a dozen others, including many more with pending applications. (Toronto’s first permanent site opened last week.) Allowing pregnant women at these sites has been recommended from the beginning, according to a 2002 report from the Canadian HIV/AIDS Legal Network.

The oldest Canadian facility is Insite, the first supervised injection site in North America. Since opening in Vancouver in 2003, there have been 3.6 million clients who have injected drugs at Insite, with 6,440 reversed overdoses and zero deaths, according to data provided by the facility. Insite’s protocol is to encourage pregnant women who visit to go into detox, or to refer them to Sheway, a pregnancy outreach program in the city’s Downtown Eastside neighborhood.

“But if they are hell-bent on injecting drugs, we would prefer them to do it in Insite under supervision of nurses, rather than an alley where there’s nobody there to help,” says Anna Marie D’Angelo, former senior media relations officer at Vancouver Coastal Health, which runs Insite. “So it’s not taken lightly and it’s not encouraged, but certainly it’s case-by-case and it’s done in the best interest of the patient.”

Ottawa Public Health opened a supervised injection facility at the end of September. Their policy, supported by opioid substitution therapy, is similar.

“Pregnant clients are able to access all harm reduction services offered by Ottawa Public Health, including supervised injection services,” wrote Donna Casey, a program and project management officer, in an email. “Health and treatment services should be targeted to meet the individual needs of the person accessing services.”

A client of the Insite supervised injection Center in Vancouver, Canada, collects her kit on May 3, 2011. Visual: Laurent Vu The/AFP/Getty Images

Whether these philosophies could ever really take hold in the United States is an open question — particularly given official disinclination toward supervised injection facilities in general, much less for use by pregnant women. But efforts underway in Australia and Canada have been watched closely by activists in the U.S.

Among them is Ria Tsinas, an Oregon-based mother who understands being opioid-dependent and pregnant. At 35, she relapsed during pregnancy and went into labor at 23 weeks. Her baby was born at one pound, 11 ounces. “She had staph, three blood transfusions, a heart operation — all the fun stuff,” Tsinas says. “Now she’s two and perfectly healthy.”

Tsinas is now working with the National Perinatal Association, a Missouri-based nonprofit, to create a toolkit for perinatal substance use. She believes her health care was “held hostage” because of her drug use, but says such prejudice is not exclusive to hospitals. “There’s still stigma about drug use and pregnancy within the harm reduction community,” Tsinas says. “It’s one of the most ignored and least talked about topics in harm reduction.”

At the Peoples Harm Reduction Alliance in Seattle, a peer-run organization that promotes safer drug use, Tsinas volunteered alongside Joelle Puccio, a travel nurse who specializes in neonatal intensive care units. Puccio sees many babies with neonatal abstinence syndrome, where they’re born dependent on opioids.

“The thing that kills any substance user is stigma,” Puccio says. “If we say everyone can use this except pregnant women, that’s extremely gender discriminatory and unethical. It’s a health care intervention. Pregnant people shouldn’t just be allowed, they should be encouraged, and they should move to the front of the line.”

That remains a tough sell in the U.S. For three years, an unauthorized supervised injection facility has successfully operated underground, according to a study in the American Journal of Preventive Medicine. (Its location has not been disclosed.) But attempts to bring above-board facilities to the U.S. have mostly been met with fierce opposition. The idea is noticeably absent from the Trump administration’s long-awaited report on combating addiction. Several towns in Washington have passed resolutions banning such sites this year, while the city of Seattle was forced to sue early last month to prevent a public vote that would block its plans for the nation’s first supervised injection sites there. A judge later sided with the city and struck down the initiative, a decision the vote’s backers have vowed to appeal. Meanwhile, a nearby county preemptively banned the sites, a Senate candidate vowed to fight against them, and some citizens raised concerns about pregnant women using the facilities.

The Massachusetts Medical Society lobbied for a supervised injection facility in Boston, but the plan is hung up on political opposition. Ithaca, New York’s mayor has expressed support for such a facility, pending approval by state legislators, while Denver officials explore a similar proposal. Even Washington, D.C. lawmakers are considering the idea.

California came closest to opening injection sites in six counties in September, spurred by a bill that fell two votes short. Democratic Assemblywoman Susan Eggman, who introduced the bill, says she was surprised it failed. She also says her bill would have allowed municipalities to decide themselves whether to allow pregnant women, but otherwise she sees no reason to turn someone like that away.

Eggman says she will try again next year. In the meantime, overdose mortality continues to rise in the U.S. — last year totaling more than 64,000 fatal overdoses, more than the entire wars of Iraq and Vietnam.

“We have an epidemic on our hands,” Eggman says. “We seem to just want to try the same things of criminalizing it and judging it and making people feel like failures.”

As for Sara in Baltimore, she gave birth to a healthy, 7-pound, 1-ounce girl. The 25-year-old mother was put into a court-mandated program at the Center for Addiction and Pregnancy at Johns Hopkins University, where she was prescribed methadone throughout her pregnancy, and continues to use today.

Although supervised injection sites don’t exist in Baltimore, Sara says she “absolutely would have used them.”

“I wouldn’t have had to put myself at risk of rape and arrest and violence and disease,” she wrote in a Facebook message. “I could have kept the drugs out of the house 100 percent. I wouldn’t have been at risk to OD and overall my safety would be better.”

Neeraj Gandotra, the medical director at the Center for Addiction and Pregnancy says pregnant mothers are actually at higher risk for withdrawal symptoms than a typical drug user, because they have a greater volume of distribution for opiates. That is, having a fetus adds more mass and blood vessels, which can create the need to increase the opiate dosage over the course of the pregnancy.

Gandotra says the best procedure is to get the mother on a standardized opioid dose, usually methadone or buprenorphine. Not even considering adulterants, street drugs have too many variables — any shift in purity or availability can cause fluctuations in the mother’s sympathetic nervous system regulation. Constriction of umbilical arteries alters blood flow and nutrition to the child, creating a high-stress state and loss of fluid around the placenta during withdrawal, which can affect the growth of the baby.

Out of 11 health care workers and addiction specialists I spoke with, Dr. Cidambi and Gandotra were the only two not entirely on board with the idea of supervised injection sites for pregnant women, at least when there are better options available.

“I don’t see a need for that when we have 30 methadone and suboxone programs, as well as a hundred providers, as well as 100 detox beds in Maryland,” Gandotra says. “So in that setting, I wouldn’t necessarily see a need to have sanctioned places where people could inject. In a situation where resources are much more scarce or in a setting where those resources weren’t available, certainly we would go with harm reduction.”

But Jauncey argues you can’t have that conversation regarding treatment with a mother if you don’t first get her in the door.

“The best possible outcome comes from connecting and engaging with somebody,” Jauncey says. “Regardless of whether we approve or wish it wasn’t happening, allow it to occur in the safest, possible manner, where we are then there to pick up the pieces, and continue that non-judgmental connection. Then our chances of actually successfully getting her into treatment in a specific drug use and pregnancy service are vastly improved.”

Troy Farah is an independent journalist from California. His reporting and criticism covering drug policy and harm reduction has been published in The Outline, VICE, The Fix and others. He can be reached on Twitter at @filth_filler.