Recently, the Health Resources & Services Administration (HRSA) hosted a webinar titled “Addressing Meth Use in the Midwest: Meth and Pregnancy” featuring speaker Dr. Marcela Smid, a maternal fetal medicine and addiction medicine physician at the University of Utah. Dr. Smid addressed both the state of the meth crisis and the social aspects of care and treatment that impact a person’s recovery, emphasizing the importance of accurate terminology.
Addiction itself is a commonly misunderstood topic. Although it is often portrayed as a character flaw of the person suffering from the substance use disorder, the actual definition is “a primary, chronic disease of the brain of reward, motivation, memory, and related circuitry.” In other words, substance use disorders are in the brain, not in behavior. “The behavior is a symptom of the condition,” Dr. Smid said, and is not a choice. “Substance use in a person who doesn’t have an addiction is a choice. But once somebody has an addiction, it is no longer a choice. It is a symptom of the condition.”
The way in which media and society depicts addiction, however, makes it difficult for people suffering from addiction to get the help they need. When people think of addiction as a choice rather than a neurological disorder, they are less likely to have empathy and support treatment, and more likely to blame the people suffering for their disorder. Similarly, when people think of addiction as seeking highs instead of avoiding lows, it becomes easier to trivialize the disease and imagine that someone has a substance use disorder because of some moral failing. This attitude creates a culture of shame around substance use disorders that hinders the creation of helpful treatment tools and diminishes the likelihood that a person will feel comfortable with or capable of seeking the help they need. “When we refer to it as a choice, we are really stigmatizing the medical condition.”
“Most people, especially once they’re in the throes of their addiction, no longer are trying to get high. They’re trying to not feel bad,” said Dr. Smid. “People who are in the middle of an addiction know they don’t want to use. They want to not feel terrible.”
Contributing to this culture of misinformation around addiction is the tendency to refer to babies as “addicted,” which is incorrect. Infants can be dependent, and can suffer from withdrawal symptoms, but not addiction. “Referring to infants as addicted further stigmatizes the medical condition and doesn’t use the correct terminology.”
The language used to talk about addiction controls how people understand the disorder, and many common terms and phrases contribute to the heavy social stigma. Calling someone an addict or a drug abuser flattens that person into nothing but their disorder; calling them someone who suffers from addiction or a substance use disorder centers the person and describes their situation accurately. Terms like relapse or slip carry a connotation that the individual is fighting a battle of morals and willpower, and therefore that resuming use came from a moment of moral weakness. Using language like “recurrence of symptoms” more appropriately describes the person’s situation without blaming their moral compass. Even words like “clean” or “dirty” to describe test results place moral judgment on the person getting their results. Dr. Smid recommended the Addiction-ary as a comprehensive resource to learn more about language and addiction.
Meth Use and Pregnancy
Decades ago, the Mississippi River was one of the country’s landmarks in the addiction crisis, with methamphetamines primarily afflicting the west and fentanyl more prominent in the east. However, with the industrialization of meth production and increasing prevalence of fentanyl, these drugs have overlapped in increasingly dangerous ways. Fentanyl has taken over as the primary cause of overdose deaths, and stimulant overdose is also rising rapidly.
A recent 67% rise in methamphetamines testing positive for fentanyl connects these phenomena in deadly ways. There is also an increasing number of individuals suffering from both opioid use disorder (OUD) and meth use disorder (MUD), exacerbated by myths about stimulants preventing overdose. In reality, the combination increases lethality by compounding cardiovascular and pulmonary effects.
“Of the individuals that we see who have opioid use disorder, half of those have a co-occurring methamphetamine use disorder,” said Dr. Smid. Between 2015 and 2019, methamphetamine-related deaths increased 180%, and methamphetamine use disorder without injection has tripled among women and doubled among men. People of color have seen an especially sharp rise, facing a tenfold increase in deaths.
The impact of rising drug use on maternal health, especially in rural areas, continues to grow, but very little data on the effects of stimulants on pregnancy exists to offer guidance about best practices. “The most important thing is that because of the stigmatization of meth use during pregnancy, all of our data is complicated by poor prenatal care and poor pregnancy dating,” said Dr. Smid. “There’s good data to suggest that both patients and providers lead with child protective services and lead with, ‘You’re doing something illegal and wrong.’”
More than 1 in 5 women with a co-occurring OUD and MUD, and more than 1 in 10 with OUD or MUD, experience severe maternal morbidity and mortality. This includes serious health events, such as heart attacks or death. Despite the severity of health outcomes facing pregnant people who suffer from substance use disorders, many may avoid seeking care. “This is the question: ‘Is my baby going to get taken away?’” Dr. Smid acknowledged that substance use is the most common reason for children to be separated from families, so these concerns were not unfounded. This is especially true for people of color, who are much more likely to face orders that separate children from their families.
What Should Be Done
“Harm reduction, even in pregnant and postpartum individuals, is the name of the game,” said Dr. Smid. The primary means of harm reduction are increasing outreach and education, offering needle exchange to reduce HIV, hepatitis C, and other infections, providing overdose prevention education, and ensuring access to naloxone and fentanyl test strips. Test strips are especially important with fentanyl on the rise. “If you’re using methamphetamines, you should assume it is contaminated with fentanyl and make sure that you’re not using by yourself.”
Asked about how to tactfully handle mandatory reporting, Dr. Smid paused. “It’s a really complicated response,” she said, starting with an explanation of how her organization in Utah had seen success working with a responsive legislature to change policy, enabling them to choose whether or not a substance use patient has to be reported, or whether they could move ahead with treatment.
When a patient’s addiction is severe enough that they clearly cannot care for themselves, reporting is the best option. “But many of you are not in that situation. You’re caught in that catch-22 where you feel like you have to report.” Reporting someone who has come to the clinic seeking help may not always be the right choice. “It feels like you’re punishing them for actually disclosing it to you when they’re seeking help.”
“There are some folks that say you don’t have to participate in a system that creates worse outcomes, and that your dissent in participating in that is a message to the system that you’re not going to report somebody who came in and got into recovery. But you are then technically breaking the law, and you have to decide that with your own moral compass.”
The alternative, said Dr. Smid, is “You are honest. You are honest with the patient, and you say, ‘I’m making this report because I have to, and I’m doing this for these reasons.’ And people may be mad at you.” Explaining the reasons for the report to the patient as honestly as possible can help the situation seem less like a punishment, although the report will have its own consequences. “Starting at policy change in your individual locations is also really where you’re going to make that shift.”