Project CARA helps expectant mothers with substance-use disorders

Leigh walked into the family nurse practitioner’s office and burst into tears. She had no insurance, a toddler to raise and a serious substance use problem. Now she was pregnant with her second child.

“I sat there sobbing, pregnant and scared,” Leigh remembers. “There was no way I could pass a urine drug test, and I needed help.”

Drugs had wreaked havoc in her life. Leigh had faced jail time and survived an overdose. She went to that first prenatal appointment at the Mountain Area Health Education Center full of fear and expecting judgment and a lecture. Still, she was ready to risk whatever it took to seek survival for herself, her child and the baby inside her.

“I had a special-needs child, zero support and no coping strategies,” she says. Her provider was Melinda Ramage, clinical director and co-founder of Project CARA, MAHEC’s perinatal substance-use treatment program.

“Melinda Ramage did not bat an eye,” Leigh recalls. “She hugged me and she said, ‘We’re going to be good friends. We’re going to take such good care of you.’”

Leigh had wanted a quick fix for her troubles. At MAHEC, she got quick kindness, but it took intense work to recover from her substance-use disorder. She has no regrets about reaching for help.

“Project CARA saved my life,” Leigh says. “It was the first time anyone taught me to respect myself.”

Safe space

Project CARA stands for Care that Advocates for Respect, Resilience and Recovery for All. Leigh came to the project in its formative stages, when the co-founders were working on building a program housed at MAHEC Ob/Gyn Specialists to decrease barriers and the stigma that prevents pregnant women with substance-use disorders from getting quality obstetrical care as well as access to substance-use treatment.

Last year, Project CARA provided services to 230 women with substance-use disorders from 16 WNC counties. According to researchers working with the project, roughly 400 babies born in the Mission Health system over the same year had exposure to illicit drugs while in utero. While deliveries at Mission don’t account for all births in the region, these numbers suggest that a substantial portion of area mothers who gave birth with a substance-use disorder were offered some form of substance-use treatment during their pregnancies. MAHEC adds, “Research on the program has demonstrated that women who participated in CARA in 2017 were 36.5 percent less likely to test positive at delivery for illicit drugs than women tested at delivery prior to Project CARA’s inception in 2014.”

Prenatal visits are often the first time a woman with a substance-use disorder surfaces on the wellness radar, and it presents an opportunity for change. Project CARA works with patients to create individualized action plans in which health takes precedence over other concerns.

“If we want healthy moms, we have to give them a safe space where they can let us know they need help,” Ramage said.

Project CARA, housed at MAHEC’s high-risk obstetrics unit, includes partnerships with the Women’s Recovery Center, Julian F. Keith Alcohol and Drug Abuse Treatment Center, Vaya Health and Mission Hospital’s Perinatal Substance Exposure Project. Together they provide substance-use treatment and recovery services, obstetrical care and community-based support. The team members keep each others’ numbers on speed dial, so they can make referrals to support each woman’s unique needs.

“We’re taking the fear out of getting treatment,” says Tammy Cody, director of Mission’s Perinatal Substance Exposure Project. “Our collaboration strengthens obstetrical and gynecological care, and helps us make a plan for safe care for moms and babies.”

Healthy pregnancy and beyond

Marie Gannon, behavioral health director and co-founder of Project CARA, had worked in substance use treatment for 15 years but was first drawn to working with pregnant women during her own pregnancy. She realized then how stressful pregnancy and the postpartum period could be, especially when coupled with a chronic disease like a substance-use disorder.

“Care coordination extends 18 months,” says Angelique Ward, a peer support specialist who works with Project CARA patients through Vaya Health. “We meet and work with mothers during their pregnancy for as long after delivery as they need.”

Three years after Leigh first visited MAHEC, she returned to Project CARA, pregnant again. This time, she was in sustained recovery from her substance-use disorder, and she wanted extra support to ensure she stayed clean and sober.

“I had gotten off drugs and I didn’t want to go back,” Leigh says. “I had a [cesarean] section with my previous pregnancy, and I was having a hard time finding a provider who would listen to my concerns about being prescribed opioids if I needed another C-section.”

Women with substance use disorders are at greater risk for relapse during pregnancy. Leigh felt so determined not to relapse that she refused to take anything but over-the-counter medications for pain relief, even when she did end up requiring a second C-section. The staff at Project CARA helped her advocate for the childbirth experience that felt safe and right for her.

“Substance-use disorder is a brain-based disease, not a failure of willpower,” Gannon explains. “Chronic diseases require individually tailored medical interventions and sustained care.”

Project CARA’s partners work together to remove barriers to health, whether that means providing transportation to a prenatal visit or helping secure safe housing or getting a patient signed up for the Special Supplemental Nutrition Program for Women, Infants and Children, known as WIC. They also help women heal from the trauma that underlies addiction.

“You can be addicted to anything – alcohol, spending money, cookies – you can overindulge in anything,” Ward said. “We work to get to the source of the addiction.”

Targeting treatment

Chronic diseases often need careful monitoring to protect both mother and child in pregnancy, Ramage says. Nationally, the rate of pregnant women with opioid use disorders at the time of delivery more than quadrupled between 1999 and 2014, according to the national Centers for Disease Control and Prevention.

To address this epidemic, Project CARA offers medication-assisted treatment with buprenorphine. The American College of Obstetrics and Gynecology and the American Society of Addiction Medicine endorse this treatment as the best evidence-based practice for reducing the risk of relapse during pregnancy. Since each mother has different needs, the treatment is individualized. Project CARA also helps with supportive services that may include transportation to appointments.

Babies born with neonatal abstinence syndrome experience withdrawal symptoms, including tremors, seizures, irritability and diarrhea. The National Institute on Drug Abuse says that women treated with buprenorphine and methadone carried their babies longer and gave birth to infants with less severe symptoms, a shorter treatment time and a higher average weight at birth.

“Relapse is part of all chronic medical conditions,” Ramage says. “I compare it to someone with diabetes who splurges on sugary foods or someone with high blood pressure not taking prescribed medication. You would never say those people had failed; instead, you would help them move forward.”

The N.C. General Assembly recently authorized $31 million to combat the opioid epidemic, and the agencies partnering on Project CARA hope to apply some of those funds to help pregnant women. Nationwide, health care costs associated with maternal opioid use and hospital stays to treat neonatal abstinence syndrome total $1.5 billion annually, and 81 percent of that amount is paid by state Medicaid funds, according to the National Institute on Drug Abuse.

“Success is different for every woman,” Gannon says. “For some of our patients, success is going home from the hospital with their baby. For others, it’s having extended family care for their baby while they build a stronger foundation in recovery. Whatever their goals are, we help them create a plan that supports them.”

Denise Weegar, director of Women’s Recovery Center, says that Project CARA has had good results, with many mothers going home with their babies and sustaining their recovery after childbirth. Being treated with dignity and respect helps them heal. Receiving services through Project CARA also helps demonstrate mothers’ commitment to recovery, which can help them keep their families intact if social service agencies become involved in their lives.

“Women are active participants in their own plans here,” Weegar says. “We hear over and over that it’s the first time some of the women realize that they are worthy of care themselves. We build relationships, so each person can find a way back here when they’re ready.”

Weegar says that Project CARA has been the starting point for many recovery journeys. She has been in her own recovery while supporting other women in theirs for more than 25 years.

Finding her tribe

When a person walks away from drug use, she often has walked away from her circle of friends, too. Besides helping her through two pregnancies, Project CARA has helped Leigh find community support.

“I now have a tribe of support with my fiancée, aunts, uncles, grandparents and friends,” Leigh says. “A lot of good came with me being willing to talk about my substance-use disorder. Every day that I wake up sober and healthy, a mom taking care of my family, is another opportunity to rebuild trust.”

Leigh became a member of Sober Mommies and with her new sense of self-worth, she has learned to accept the caring of family and friends.

“For me, success is about more than staying clean and sober,” Leigh says. “It’s about owning my own house. It’s about having children who are proud of me. It’s about having a good job and a family that can trust and rely on me. Other women can see me and feel hope for themselves.”