When Elizabeth learned that she was pregnant, she cried tears of joy. “I heard his heartbeat, and that was it,” she says. (Xpress is using her middle name to protect her privacy.) It was then that she decided to get clean.
Elizabeth learned of her pregnancy while incarcerated for crimes she committed to support her addictions to methamphetamines and opioids, she tells Xpress. After eight months at the N.C. Correctional Institution for Women in Raleigh, she left prison in early 2019.
Three days later, she had an appointment at Project Care that Advocates Respect, Resilience and Recovery for All, an outpatient clinic for people with substance use disorder at Asheville’s Mountain Area Health Education Center.
Project CARA seeks to address the “intersection of reproductive health, substance use disorders as chronic diseases and the needs that are unique when those two things intersect,” says Melinda Ramage, the clinic’s medical director. Since 2014, Project CARA has served over 800 pregnant and parenting patients like Elizabeth; 2020 saw 290 patients, the most yet.
In addition to continuing the prenatal care Elizabeth received in Raleigh, Project CARA prescribed her Suboxone, a medication that reduces opioid withdrawal symptoms and cravings, at her first appointment. Today, she is the proud mother of a 2 1/2-year-old boy who loves NERF guns, watching Blaze and the Monster Machines and dinosaurs. “He can name T-rex, triceratops, stegosaurus — he’s very smart,” she says.
A safe space
A common misunderstanding about mothers with substance use disorders is that “these women don’t love their children — if they did, they would stop,” says Tammy Cody, a social worker with Project CARA. “All of the women love their children and care for them, and that’s why they’re seeking care. Often the substance use is a result of the trauma they’ve experienced in their history.”
Project CARA creates a safe space for patients’ openness and honesty, explains Ramage. Elizabeth struggled after losing someone close to her due to an overdose. “I didn’t know how to deal with that grief without turning back to the same thing I always had,” she says.
The clinic revives the Mountain Area Perinatal Substance Abuse Program, a 1990s MAHEC effort that primarily treated cocaine and heroin use disorders, Ramage says. Current patients are 24-27 years old on average, primarily white and use Medicaid health insurance, according to Sedona Koenders, a research project coordinator for UNC Health Sciences at MAHEC.
Project CARA patients represent 23 counties in North Carolina, plus Tennessee and South Carolina, she continues; 50% of the patients are from Buncombe County. They arrive, like Elizabeth, through self-referrals, or via OB-GYNs and substance use treatment facilities.
According to the Guttmacher Institute, 19 states, including North Carolina, have created drug treatment programs for pregnant women. But in 23 states and the District of Columbia — including several with treatment programs — substance use during pregnancy is considered child abuse. (In 2020, the General Assembly passed House Bill 918, which would have classified substance use during pregnancy as child abuse in North Carolina, but Gov. Roy Cooper vetoed the legislation.)
Substance use experts say that such laws can undermine trust in the doctor-patient relationship. A January 2020 article in North Carolina Medical Journal says “reducing barriers to care for women is essential, because if a woman does not show up or stay for treatment, she, her children and her family will not reap the benefits of treatment.”
Adds Ramage, “Being punitive does not help people feel safe enough to tell you what’s hard about what they need.”
Continuity of care
Project CARA tries to provide everything a pregnant woman with a substance use disorder needs in one place: pregnancy and postpartum care, behavioral health, substance use care and help navigating social service agencies.
Elizabeth took advantage of all these services; her Project CARA therapist proved to be crucial. She hadn’t always felt that previous substance abuse counselors understood her, she says, but the clinic’s providers were nonjudgmental and didn’t show preconceived notions about people with addictions.
Social workers like Cody help patients develop individualized treatment plans and prepare for everything from nonnarcotic pain management during childbirth to involvement with the Department of Social Services up to a year postpartum. For Elizabeth, that preparation meant understanding that her son may be admitted to Mission’s newborn intensive care unit. She anticipated that her son may be born addicted to Suboxone, but she says nothing could have readied her emotionally for the experience.
“That was one of the hardest things I think I’ve ever had to see, my son going through withdrawals,” she recalls, her voice cracking. “It almost makes me want to cry talking about it.”
Elizabeth was also prepared by Project CARA as to what might happen in a Child Protective Services investigation after the birth if there is evidence of illicit or illegal substance use. Hospitals are required to notify DSS if an infant is experiencing substance withdrawal.
“I felt like I was being looked at through a magnifying glass, because I’m sure I was,” Elizabeth says of the DSS meeting. “Which was fine; I have nothing to hide. But it was intimidating, because they had the power to take my kid away.”
Though these topics are heavy, Cody says, discussing them before delivery brings mothers-to-be great relief.
Asking hard questions
Project CARA is participating in a nationwide study that seeks to understand the best approaches for treating opioid abuse. In 2019, the Pew Charitable Trusts, a global nonprofit, selected the clinic as one of six initiatives to be funded for evaluation as part of its Community Opioid Response and Evaluation project.
“Understanding the most effective ways to prevent overdose deaths and provide treatment is critical to curbing the opioid crisis, as it can encourage state and local leaders to invest in evidence-based programs,” Beth Connolly, project director of Pew’s substance use prevention and treatment initiative, writes in a statement to Xpress. If Project CARA’s model is effective, it could be adopted across the country, she adds.
Researchers for the Pew study will ask respondents about patient experiences, the care they received, if they felt the care they received was respectful and other topics, Koenders with UNC Health Sciences explains. Those findings will be supplemented by Project CARA’s own data about maternal and newborn outcomes.
So far, the Pew study has collected 22 sets of information from surveys and interviews. Participants are being recruited on social media and with fliers placed at MAHEC, substance use treatment centers and obstetric clinics throughout WNC. The study will continue through at least December, says Koenders.
Although Project CARA has incorporated input from patients since it began, its leaders want to continually reassess the program. The staff is grateful that the Pew study is providing an opportunity to solicit more input from patients. Says Ramage, “We need to remain unafraid of those hard questions, because the answers are worth it.”
Elizabeth credits Project CARA with helping her adjust to parenthood and sobriety — “learning how to live life.” She’s grateful that the program existed. “Because I needed help,” she says.