Problematisation and regulation: Bodies, risk, and recovery within the context of Neonatal Abstinence Syndrome

'Planning for a healthy baby and a healthy pregnancy': A critical analysis of Canadian clinical practice guidelines for the treatment of opioid dependence during pregnancy

As opioid fatalities rise in North America, the need to improve the supports available to those who are dependent on opioids and pregnant has become more urgent. This paper discusses the social organisation of drug treatment supports for those who are pregnant, using Canadian clinical practice guidelines (CPGs) for methadone maintenance treatment (MMT) as a case study. Pregnant patients are a priority population for MMT, both in Canada and internationally; the regulatory bodies that oversee MMT in Canada are the provincial Colleges of Physician and Surgeons and Health Canada. The paper analyses MMT CPGs published by these agencies, comparing their general recommendations to those specific to pregnant patients. We demonstrate that the guidelines address few treatment considerations for pregnant patients, other than improved birth outcomes and child welfare, despite acknowledging their more complex needs. Drawing on social science studies of gender and drugs, we argue that MMT CPGs therefore perpetuate the intensified surveillance and foetal prioritisation that have long generated barriers to care for opiate-dependent pregnant patients. We also discuss how and why the CPGs ultimately only reinforced these current limitations in the drug treatment sector.

Implementation of State Laws Giving Pregnant People Priority Access to Drug Treatment Programs in the Context of Coexisting Punitive Laws

BACKGROUND

In response to increased prenatal drug use since the 2000s, states have adopted treatment-oriented laws giving pregnant and postpartum people priority access to public drug treatment programs as well as multiple punitive policy responses. No prior studies have systematically characterized these state statutes or examined implementation of state priority access laws in the context of co-existing punitive laws.

METHODS

We conducted legal mapping to examine state priority access laws and their overlap with state laws deeming prenatal drug use to be child maltreatment, mandating reporting of prenatal drug use to child protective services, or criminalizing prenatal drug use. We also conducted interviews with 51 state leaders with expertise on their states' prenatal drug use laws to understand how priority access laws were implemented.

RESULTS

Thirty-three states and the District of Columbia have a priority access law, and more than 80% of these jurisdictions also have one of the punitive prenatal drug use laws described. Leaders reported major barriers to implementing state priority access laws, including the lack of drug treatment programs, stigma, and conflicts with punitive prenatal drug use laws.

CONCLUSIONS

Our results suggest that state laws granting pregnant and postpartum people priority access to drug treatment programs are likely insufficient to significantly increase access to evidence-based drug treatment. Punitive state prenatal drug use laws may counteract priority access laws by impeding treatment seeking. Findings highlight the need to allocate additional resources to drug treatment for pregnant and postpartum people.

Barriers and Motivators to Opioid Treatment Among Suburban Women Who Are Pregnant and Mothers in Caregiver Roles

Women of childbearing age who misuse opioids are a particularly vulnerable population, and their barriers to treatment are unique because of their caregiver roles. Research on treatment for opioid use generally draws from urban and rural areas. This study fills a gap in research that focuses on barriers and motivators to opioid treatment in suburban areas. The aim of this study was to give voice to suburban pregnant women and mothers caring for children while using opioids. Ethnographic methods were used for recruitment, and 58 in-depth interviews were analyzed using a modified grounded theory approach. Barriers to medication-assisted treatment (MAT) included stigma, staff attitudes, and perceptions the women had about MAT treatment. Barriers associated with all types of treatment included structural factors and access difficulties. Relationships with partners, friends, family, and providers could be barriers as well as motivators, depending on the social context of the women’s situation. Our findings suggest increasing treatment-seeking motivators for mothers and pregnant women by identifying lack of resources, more empathetic consideration of social environments, and implementing structural changes to overcome barriers. Findings provide a contemporary understanding of how suburban landscapes affect mothers’ treatment-seeking for opioid dependence and suggest the need for more focus on emotional and structural resources rather than strict surveillance of women with opioid dependence who are pregnant or caring for children.

Diagnosing uncertainty, producing neonatal abstinence syndrome

The use of alcohol and other drugs during pregnancy is understood to be an important public health problem. One way in which this problem is expressed and responded to is via the identification and treatment of neonatal abstinence syndrome (NAS). In this article, we demonstrate how the processes of anticipating, identifying and responding to NAS are characterised by significant uncertainty among parents and health and social care practitioners. We draw on interviews with 16 parents who had recently had a baby at risk of NAS, and multidisciplinary focus groups with 27 health and social care professionals, held in Scotland, UK. NAS, and drug use in pregnancy, is a fraught and complex arena. Parents in the UK who use opioids risk losing custody of children, and must navigate a high degree of surveillance, governance and marginalisation. We suggest that considering NAS as a social diagnosis, further informed by Mol's political ontology of 'multiple' bodies/diseases, may help to produce clinical and social responses to uncertainty which avoid, rather than promote, further marginalisation of parents who use drugs. One such response is to develop a culture of relationship-based care which empowers both service providers and service users to challenge existing practice and decision-making.

Understanding and managing uncertainty in health care: revisiting and advancing sociological contributions

In this collection we revisit the enduring phenomenon of uncertainty in health care, and demonstrate how it still offers coherence and significance as an analytic concept. Through empirical studies of contemporary examples of health care related uncertainties and their management, our collection explores the different ways in which uncertainty may be articulated, enacted and experienced. The papers address a diverse range of healthcare contexts - Alzheimer's disease, neonatal surgery, cardiovascular disease prevention, cancer, addiction (use of alcohol and other drugs during pregnancy), mental health/disorders and medical education - and many tackle issues of contemporary relevance, such as an ageing population, and novel medical interventions and their sequelae. These empirical papers are complemented by a further theoretical contribution, which considers the role of 'implicit normativity' in masking and containing potential ethical uncertainty. By mapping themes across the collection, in this introduction we present a number of core analytical strands: (1) conceptualising uncertainty; (2) intersections of uncertainty with aspects of care; (3) managing uncertainty; and (4) structural constraints, economic austerity and uncertainty work. We reflect on the methodological and theoretical stances used to think sociologically about uncertainty in health care, and the strengths, silences and gaps we observe in the collection. We conclude by considering the implications of the insights gained for 'synthesising certainty' in practice and for future research in this area.