NC addiction treatment programs partner to reduce maternal deaths from substance use

By Rachel Crumpler

Overdose is a significant cause of maternal death in North Carolina, according to the state’s latest maternal mortality review. 

Among the 76 pregnancy-related deaths that occurred in North Carolina in 2018 and 2019, a little over one quarter — 20 deaths — were from overdoses. Nearly all of the deaths were related to opioids, with fentanyl involved in 14.

“That’s shockingly horrific,” said David Ryan, an OB-GYN and addiction medicine doctor at ECU Health.

And the deaths are just the most extreme cases, he explained. Many more pregnant women are in the grips of addiction and nearly die, or are unable to access treatment that could help them. Others are not identified as having a substance use disorder because of poor screening or because they skip health care appointments for fear of being stigmatized for their substance use. 

Overdose deaths account for a growing share of maternal deaths nationally; overdose deaths in pregnant or postpartum people increased by 81 percent between 2017 and 2020, according to research published in the Journal of the American Medical Association.

Overdose during the perinatal period is something that doesn’t get talked about enough, said Elisabeth Johnson, who has worked with pregnant women with substance use disorder at UNC Horizons for more than 11 years. The Carrboro-based program provides residential and outpatient recovery services. 

In 2020, between 8 percent and 11 percent of pregnant women ages 15 to 44 reported using illicit drugs, tobacco products or alcohol in the previous month, according to a national survey on drug use and health that included more than 36,000 interviews conducted by federally funded researchers.

Substance use disorder during pregnancy is associated with negative health outcomes for mothers and infants, including preterm birth, stillbirth and fetal development problems such as brain abnormalities.

“There’s a lot of stigma that patients with substance use disorder face, but then we put pregnancy on top of it, it is stigma on top of stigma,” Ryan said.

Despite the prevalence of perinatal substance use disorders, Ryan said gaps in care across North Carolina often make treatment difficult to access. 

However, Ryan stressed the importance of making treatment, including medications for opioid use disorder, accessible during pregnancy and the postpartum period. It’s a key time when patients are generally more motivated to change, he said, explaining that a mother will often do more for her recovery while pregnant to protect the child than she may have done for herself alone.

“This is a population of patients who are willing to make a change, who are capable or who maybe have the ability to make a change that they haven’t been able to make in a really long time,” Ryan said. “And we pour the least amount of resources, time, money and energy into these patients who are most susceptible to the interventions that we want to offer.”                  

Gina Hofert agrees that more needs to be done for this population. She’s CEO of the Suda Institute, which oversees the SUN Project in Cabarrus County — a collaborative program providing support to mothers navigating substance use challenges and caring for their infants.

“[Perinatal substance use disorder] is still one of the things that has the greatest stigma, and one of the things that providers seem the most uncomfortable with when it comes to screening, treating, collaborating and addressing in the health care field,” Hofert said.

Six perinatal substance use disorder programs across the state are on a mission to change that. 

The programs partnered to form the North Carolina Perinatal Substance Use Disorder Network — with support from a grant from insurer Aetna — to harness their collective expertise and share best practices for treating people with perinatal substance use disorder statewide, expand access to treatment and advocate for policy changes.

“We need to be doing this care for everyone, everywhere,” said Mel Ramage, director of the network and a family nurse practitioner who has treated patients with substance use disorder for over a decade.

Too few providers

The six programs making up the network provide comprehensive perinatal substance use disorder treatment. Following best practice, the programs work to provide — in one place — access to everything a pregnant woman with substance use disorder needs: prenatal care, behavioral health, medications for opioid use disorder and even help navigating social services. 

However, these programs’ capacities don’t meet the demand for substance use treatment across the state. 

Ramage said one of the biggest barriers to accessible perinatal substance use disorder treatment is the low number of providers in the state that offer it. For pregnant patients who use opioids, prescribing medications for opioid use disorder — buprenorphine or methadone — is considered best practice. These medications have been shown to result in better outcomes and reduce the risk of relapse.

However, finding a provider willing to serve these patients is difficult. Some doctors treat pregnant patients, and others treat substance use; few do both.

Amy Marietta, a family physician in western North Carolina, sees pregnant patients with substance use disorder and can prescribe buprenorphine.

While serving as the only prenatal and pediatric care provider in rural Polk County, she repeatedly saw pregnant and parenting patients at her practice with substance use issues. 

That spurred her to incorporate medications for opioid use disorder into her practice, and she said her ability to prescribe buprenorphine was a game-changer for her patients and their recovery.

“[We] see people come in in one place in their recovery,” Marietta said, “and really see the change that happens as they engage in treatment and just become this amazing mom or see them get housing or see their probation or parole cases closed.” 

Now, Marietta is medical director of MAHEC’s Project CARA in Asheville, a perinatal substance use program that serves more than 200 patients each year. But many patients have to travel for upwards of an hour each way to reach Asheville or any of the state’s other perinatal substance use disorder programs. 

It’s a long haul, particularly for frequent prenatal visits for a population that often already struggles with practical barriers like access to transportation, time off work and child care.

Many patients also accumulate negative experiences before making it to one of the state’s comprehensive programs. They often describe having been judged harshly for substance use, not offered treatment or simply turned away. 

For example, Ramage still remembers one of the first patients she worked with at Project CARA. Ramage said the patient told her that her drug screen at the previous clinic she went to came back positive and she admitted to the health care provider that she was using a substance. Nothing more was said. 

“This was a trained medical professional, and it just so happens I knew who they were and they had years of experience. So what stopped them from having the next step ready?” Ramage asked. “Did they panic because they didn’t know what to say so they said nothing? Did they know the skill but they didn’t know how to do it? Did they judge the patient and that stopped them in their tracks?”

Ramage and other members of the North Carolina Perinatal Substance Use Disorder Network want to build providers’ comfort in treating these patients, putting care within reach in more communities, using a “hub and spoke” approach.

Substance use and obstetrics intersect

The challenge, Marietta said, is that OB-GYNs can initially feel like treating substance use is out of their wheelhouse.

William Johnstone, an OB-GYN, originally felt that way. However, about a decade ago he had an encounter with a patient where the young woman died six weeks after giving birth because her substance use was not treated. That incident cemented for him how obstetrics and addiction medicine intersected — and how he needed to do more. 

Perhaps the biggest part of it, Johnstone said, was breaking down his own bias against these women — learning to understand addiction as the chronic disease it is, and not a moral failing. He earned board certification in addiction medicine and founded the nonprofit perinatal substance use program Tides in Wilmington.

Johnstone said the ability to prescribe medication for opioid use disorder is a “tool” OB-GYNs need, as they are certain to encounter these patients. He added that it’s now easier for providers to prescribe buprenorphine in an outpatient setting than when he started due to a federal policy change in 2023 that eliminated the X-waiver. That was a special DEA license clinicians needed to dispense the medication; it was a requirement many clinicians saw as burdensome.

“There’s a major opportunity to make opioid use disorders one of the conditions that providers who take care of pregnant patients feel confident and comfortable managing,” Marietta said. 

Empowering more providers to offer addiction treatment

One of the North Carolina Perinatal Substance Use Disorder Network’s priorities is to expand best practices across the state. The network is planning to establish a learning collaborative to empower providers with the knowledge and skills to provide care to pregnant patients with substance use disorder in their communities. 

The group plans to partner with Project ECHO Network in North Carolina to foster regionalized, peer-to-peer learning across the state.

“It’s important to bring that specialized knowledge to communities so those patients don’t have to continue going to specialists outside of where they live,” said Lucas Griffin, program manager at Project ECHO.

And there are already signs that’s beginning to happen. ECU Health plans to open a clinic this spring serving women with perinatal substance use disorder, Ryan said. 

While providers and communities aren’t expected to immediately set up programs as expansive as the existing Perinatal Substance Use Disorder Network partners, the network is ready to serve as models and happy to pass on lessons that might make their journey smoother.

“Our hope is with this statewide network, that we can start kind of building the recipe for how to create an evidence-based, trauma-informed, welcoming, nonjudgmental space where people can receive substance use disorder care during their pregnancy,” Marietta said.

It’s a powerful patient population to serve, said Johnson from UNC Horizons, the oldest program focused on targeting perinatal substance use in the state. Connecting pregnant and postpartum patients with treatment for substance use disorder is transformational, she said — people come in using heavily and struggling, and they gradually learn to thrive and raise happy, healthy children.

“If you get mom in a healthy place to be able to learn new ways to parent, then you stop that intergenerational cycle of trauma, of substance use, and you see this transformation,” Johnson said. “Mom transforms, kids transform. 

“It’s generational change.”

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