Kim Short waited in the doctor’s exam room on an icy day in February, exhausted from the first trimester of pregnancy and trembling in withdrawal from methamphetamine, alcohol, Xanax and Klonopin.

She stared at the floor, her black hair curtaining face tattoos of a dagger and stitches, memorials to friends dead from overdose. Inky wings of eyeliner rimmed her eyes.

This was Kim’s second pregnancy with the Great Moms clinic at the Corewell Health Medical Center in Grand Rapids, Mich., one of the rare programs for a population of patients who are among the most reviled in society: pregnant women and new mothers who are addicted to drugs and alcohol.

Kim, 32, had first come to the clinic in the fall of 2022 and, in April 2023, gave birth to a healthy, drug-free boy. But within months she relapsed, and child protective services placed the baby in foster care. Her despair drove her further into addiction.

Now, pregnant again, she had returned to the one place she believed was her best shot at staying sober and raising this new baby.

Dr. Cara Poland walked into the exam room.

“I’m so thankful that you made your way back to us,” she said to Kim.

Stigma and shame

Dr. Poland, an addiction medicine specialist who founded the clinic, was not like any doctor Kim had ever met.

She did not wear a white coat. At their first appointment back in 2022, Dr. Poland plopped down cross-legged on the floor of the exam room and smiled up at her new patient.

Kim, a petite woman who had been hunching inward as if braced for dismissive contempt, was startled.

Dr. Poland, an associate professor at the Michigan State University College of Human Medicine, then introduced a gaggle of students who accompanied her.

She told Kim, “It’s your job to teach them how to not be assholes to people who have addiction.”

Kim laughed, thinking, she later recalled: “I can vibe with this lady, for sure!”

Reducing the prejudice and shame felt by addicted patients is Dr. Poland’s calling. She spearheaded a program that trains doctors in other disciplines to treat addiction, a chronic brain disorder that alters circuits involving reward and self-control.

That condemnation is pervasive throughout the criminal justice system. In the child protection system, agencies routinely take custody of newborns who test positive for drugs but do not then usually offer support services to the mother. According to a May study in Obstetrics and Gynecology, those removals were associated with a greater likelihood that the women would more quickly become pregnant again and that those fetuses would have an increased risk of exposure to drugs in the womb.

That stigma is also deeply ingrained in health care itself. Many providers, surveys show, view the women as selfish and morally flawed.

Pregnant women who use drugs often delay prenatal care or avoid it entirely, medical experts say, afraid that their doctors will report them to the child welfare authorities. Most detox centers will not accept pregnant women, fearing that if the fetus is harmed, the facility could be held liable.

Dr. Poland approaches her work with the persistence of someone who was not expected to live past 20. (She is 40.) Since childhood, she has battled a cluster of rare medical conditions that left her with alopecia, for which she wears head coverings to keep her scalp warm.

Her relationships with patients are not only informed by her own experiences with chronic illness but by addiction itself: Her younger brother died by suicide at 24, following bouts of depression and alcohol use disorder.

And so in first appointments with new patients, she tries to upend the doctor-patient power dynamic in the exam room. “I sit below patients so they can internalize that they are in charge — the reverse of what they usually experience,” she said. “I’m showing that I’m just there to support them.”

When Dr. Poland began practicing addiction medicine, too many patients reminded her of her brother. But pregnancy, she realized, offered a unique opportunity to treat addiction.

“I’ve yet to meet a person who doesn’t try to change something about their health because they’re pregnant,” Dr. Poland said. “It’s a really powerful motivator. It just happens the thing my patients are trying to change is their drug use. “

In 2018 she started Great Moms (Grand Rapids Encompassing Addiction Treatment and Maternal Obstetric Management) to give patients coordinated obstetric and addiction care during pregnancy and in the critical year after birth, when they are highly susceptible to relapse and overdose. The clinic, whose staff includes a nurse-midwife and a social worker, also works with social service agencies. Patients are often assigned recovery coaches, who meet with them anywhere, even at the homes of their dealers.

With illicit fentanyl dominating the drug supply and use of meth and other addictive substances soaring, the need for programs like this one has only become more urgent. The National Institute on Drug Abuse reported in November that overdose deaths in pregnant and postpartum women rose sharply in 2021, compared with 2018, with rates more than tripling for women ages 35 to 44. In 2022, 204,000 pregnant women, or nearly 10 percent of the national total, reported using illicit drugs, including cannabis, in the previous month, according to federal data.

Their children have paid a price. Drug-related deaths in babies under a year old have risen sharply, according to a new study in The Journal of Perinatal Medicine. Newborns and infants are the fastest-growing group in foster care, according to a 2022 report by the White House Office of National Drug Control Policy. Parental drug misuse was cited in a third of cases in which a child was removed from the home.

The complex needs of pregnant drug users are gaining acknowledgment in medicine. Some hospitals, including those in Boston, Chapel Hill, San Francisco, Philadelphia, Las Vegas and Tampa offer programs with obstetric care and addiction treatment. Skeptical administrators initially viewed these clinics as enabling addiction. But in just the first year of the Great Moms clinic, prenatal care visits rose by 120 percent.

Many patients also need assistance with food and housing. Some live under the thumb of dealers and pimps who accompany the women to appointments, monitoring what they say. At Dr. Poland’s clinic, a sign in the patients’ bathroom reads: “Please place a sticker on the bottom of your urine specimen cup if you are experiencing sexual, physical or emotional abuse at home, or if there is something you would like to talk to the provider about in private.”

Alerted by the yellow stickers, the clinic has made police reports and connected women with domestic violence shelters.

Getting sober again

When Kim first came to the Great Moms clinic in 2022, heavily addicted to meth, alcohol and anti-anxiety medicines called benzodiazepines. or “benzos,” Dr. Poland asked whether she had a safe place to live.

Kim said she stayed with a “friend,” not mentioning that he was a liquor store owner 30 years her senior, who intentionally left benzos lying around.

In exchange for the drugs and rent, Kim had to have sex with him and go on “dates” with his friends — an arrangement that Dr. Poland said is not uncommon among her patients.

At Kim’s appointments, Dr. Poland reviewed urine toxicology screenings, cheering any small improvement. She asked Kim to explain how she had done it — a technique known as motivational interviewing: “Wow, you used to drink daily, and this week you didn’t drink for four days? That’s great! Tell me how you managed to do that!”

Dr. Poland also connected her with Arbor Circle, a social services agency, which assigned her a recovery coach named Hope Warren. Ms. Warren, 39, a mother of three who has been in recovery from crack cocaine since 2007, met Kim weekly at a coffee shop, helping her devise strategies to subdue urges to use, encouraging her efforts to earn money by refurbishing furniture.

Kim found that meth wasn’t that hard to resist, because it now made her nauseous. To ease her cravings for vodka, Dr. Poland prescribed naltrexone.

But Kim found abstaining from benzos excruciating. For more than 15 years, she had used them to hoist herself through each day.

She grew up in a chaotic, violent home. She ran away repeatedly, was held back in school and dropped out in ninth grade.

Lonely and insecure, she discovered that “benzos made me feel normal.” Meth woke her from their stupors.

At 15, needing drug money, she followed older friends into sex work, which she later supplemented with dancing in strip clubs. Over the years, she pinballed among pimps, homeless encampments, police raids and jail. During meth binges, she said, the bosses would bar her from dancing at the strip clubs because her ribs stuck out.

Through the years, Kim’s friends were dying from overdoses and suicide. Keenly aware that she would die too if she didn’t get help, she made, by her count, 17 frenzied attempts at recovery.

But without the swaddling of benzos and the exhilarating jolt of meth, anxiety would grip her, she said, and she would succumb to the insatiable itch to get high.

To alleviate Kim’s withdrawal from benzos, Dr. Poland prescribed muscle relaxants to address the panic attacks and pregnancy-related back pain. Gradually, with the combination of urine screenings, Ms. Warren’s unwavering support and her own tenacity, Kim got sober.

In the final weeks of pregnancy in the spring of 2023, she fled the liquor store owner’s house. She moved in with a female friend who used meth but, Kim rationalized, only in the basement.

When Kim’s baby was born, she gazed at him and vowed: “This kid is going to save my life. You are just so special. I couldn’t stop using for myself, but I am going to do it for you.”

Her meager belongings now included a starter set that the clinic gives patients: a portable crib with a travel bassinet, a half-dozen baby outfits, a diaper bag with a baby thermometer, a nostril suction bulb, a finger gum brush, diaper rash cream and a baby blanket hand-sewn by Dr. Poland and the clinic’s nurse-midwife.

At Kim’s first postpartum checkup, Dr. Poland noted that she was hopeful, excited, determined.

But Kim would later concede, “We always think that love is stronger than this disease, but that’s just not the truth.”

She began going down to the basement.

After the police raided the house that summer, she resumed couch-surfing. One night, when she had to bolt from her latest spot, she called Ms. Warren, who packed up mother, baby and belongings and drove them to a YWCA.

Eventually, hating herself, Kim slunk back to the liquor store owner.

Then, after she left her baby with a cousin and disappeared for two days in a meth house, the authorities placed her son, then 6 months old, in foster care.

After Birth

Dr. Poland has a list of explanations for why her postpartum patients miss appointments:

The baby was fussing.

No transportation.

Forgot.

Relapsed.

After Kim missed her second postpartum appointment, Dr. Poland started worrying. She called Kim herself, to emphasize that she hadn’t just been putting on “some doctor facade of caring.” At least weekly for two months, Dr. Poland left Kim voice mail messages of gentle inquiry, always inviting her to come in.

But Kim did not want to be found. Gutted by the loss of her son, humiliated by the drug chokehold she could not break, she went harder on the benzos, the alcohol and the meth.

She did not contact the clinic until this February, when she reappeared, pregnant again.

Dr. Poland tries to maintain a clinical relationship with patients for up to a year after they deliver — a period when, overwhelmed and sleep deprived, they are vulnerable to using. At those appointments, she continues drug screenings, adjusts addiction and psychiatric medications and inquires about life pressures that could destabilize patients.

Although 30 percent of Great Moms patients don’t even complete prenatal care, about 70 percent show up for visits through pregnancy, childbirth and the checkups with their 6-week-old babies. They often transition to primary care doctors.

After an appointment with Kim one morning in March, Dr. Poland had a postpartum checkup with a patient named Jessica, accompanied by her husband, Nate, who asked that their last names to protect the privacy of their infant daughter, Kaydence. While Dr. Poland held the baby, Jessica chatted happily about being a mother. But she also admitted that sober parenting was challenging. Her ability to attend daily support meetings depended on the baby’s sleeping and feeding schedule. Money was a constant worry. And she and Nate were figuring out a relationship no longer ruled by heroin.

It was hard for her to accept that she had to take buprenorphine daily to stifle her heroin cravings. “I hate having to rely on a substance, but I know it’s saving me from going back to the needle,” Jessica said. “But what really drives me is the idea that Kaydence never has to see us use drugs.”

On a recent Tuesday, Kim actually arrived a few minutes early for her 9:15 a.m. appointment with Dr. Poland. Her black hair was pinned up against the May heat. Her hoop earrings with feathers danced, and the coppery tips on black-painted nails caught the light. Because she wore a tank top, more tattoos were visible, including a ram’s head across her Aries chest. Though she was in her third trimester, she had a lightness about her.

Dr. Poland entered the exam room, her bedazzled head covering, sling-back sneakers and green-and-white manicure — Michigan State’s colors — complementing her patient’s plumage.

But this was Kim’s first visit with Dr. Poland in nearly two months.

Shortly after her March appointment, Kim confessed, she had been kicked out of residential treatment for chafing against restrictions and insisting on a different therapist.

Even though she was broke, she refused to return to the liquor store owner. A dancer from the strip club offered to share a room in a motel, where drugs were rampant.

Instability is Kim’s biggest trigger. She opened a bag of meth.

While Kim knew Dr. Poland wouldn’t scold her, she also knew the doctor might have to report positive drug screenings to foster care. That would affect Kim’s unsupervised visits with her year-old son. So she skipped clinic appointments and ducked Dr. Poland’s calls.

But a few weeks into using meth, Kim sat up. “How am I back in this situation?” she asked herself. “Like, really?” She called her foster care worker. “I got to let you guys know.”

Kim’s visits with her toddler are once again supervised.

Then she marched herself back into treatment. She found an open bed in a sober house with seven other women, attends five Narcotics Anonymous meetings a week, sees a therapist and has random drug screenings. Hope Warren, her recovery coach, checks in weekly. Kim got a job cleaning bathrooms at a concert hall.

At last Dr. Poland spoke. “There’s a difference between what I like to call an ‘episode’ and a ‘relapse,’ ” she told Kim. “You had an ‘episode.’”

Kim admitted that she sometimes feels that itch. “At first I was riding the highs,” she said. “New job. New house. Seeing my kid. But I’m starting to level out to where there’s nothing new, no highs to ride. I mean, I feel good, but there’s still that piece.”

Dr. Poland nodded. “So what are other things that make you feel good?”

Kim laughed. “I like to hula hoop!”

And she spoke proudly about the street friends seeking her advice about treatment. She has directed some to Dr. Poland and was preparing to escort a man to detox.

Dr. Poland then asked where she was planning to live, mentioning a local sober residence for mothers and babies. Kim is due in August with a girl she intends to name Phoenix Dawn.

But Kim said she was maxed out on sharing a room, asking permission from a house mother, abiding by curfews, chore charts and twice-daily alcohol breathalyzer tests.

“I still need my meetings and my therapy, but being in a place where it’s just me and the baby would be ideal,” she said.

Dr. Poland replied evenly, “The important thing is that we give you the menu of options.” Though data does show who does better in a recovery house or living independently, she said, “You’re not a data point. Only you know what is going to build the right recovery for you, right?”

Kim confirmed her next appointment and then headed to her twice-weekly hourlong visit with her son.

Moments after she arrived at the sober residence, a worn but stately home in a Grand Rapids historic district, a foster care worker appeared with Kim’s grinning, squirming toddler. While Kim cut up strawberries and hand-fed him, the worker took detailed notes. Kim read him a baby book. They played with a toy phone.

Kim couldn’t take her eyes off her son, nicknaming him Honeybear because he is, as his T-shirt proclaimed, Unbearably Cute.

Finally, he had his fill of fruit, toys and cuddles. “Little man on the move!” she called out.

As he wobbled, she gently supported him under the armpits, the worker scrutinizing them both. He lurched forward and abruptly leaned back, trying to find his balance.

“One step at a time,” Kim cooed in his ear. “You’ve got this.”

Source link: https://www.nytimes.com/2024/06/16/health/pregnancy-drug-addiction.html