By Caroline Curran, firstname.lastname@example.org
CHAPEL HILL, NC – “I don’t think evil is very creative,” John Thorp Jr., MD, said when asked about the blistering cycle of illicit drug use and the trail of destruction it leaves behind as it barrels through communities.
In the 1980s and 1990s, it was crack cocaine; today it’s opiates. North Carolina is in the thick of the current opiate epidemic, and pregnant women are not immune.
Thorp, professor and division director of general obstetrics and gynecology at the UNC School of Medicine, is the medical director of UNC Horizons, which he founded in 1994 when the advent of crack made cocaine more widely available. He was seeing pregnant women in the clinic who were using crack cocaine and realized there was a glaring hole where any treatment options should be.
“There is so much contempt for substance abuse and there’s even more contempt if you have a substance use disorder and you’re pregnant,” Thorp said.
When Thorp created Horizons – thanks largely to state money from then Governor James Martin -- there were key elements he thought would make the program different and, more importantly, successful.
Thorp wanted Horizons to address trauma in the lives of women suffering from substance use disorder, and to help women in a gender-specific, in an all-female environment.
“Childhood physical and sexual abuse are big parts of these women’s trauma,” Thorp explained. “These young women were really smart. They wanted to dampen the horror they were going through. Unfortunately, they used addictive substances to accomplish that. Or their abusers got them intoxicated before abusing them or afterword to make them shut up.”
Thorp knew his Horizons team had to address that.
Unlike most treatment programs for women, UNC Horizons added a childcare and child therapy element.
“This is crucial because our patients don’t want to leave their children. By running a therapeutic daycare, we can help the child even if the mom has end-stage disease and is not going to get well,” Thorp said. “The child being with the mother is a tremendous motivator. The third miracle of childbirth is how much the mother loves the baby.”
Today, UNC Horizons is an inpatient, residential treatment program that helps women overcome their substance use disorders while concurrently treating the underlying trauma that more than 80 percent of women who abuse drugs or alcohol suffered in either the recent or distance past. The program is open to women in North Carolina who are pregnant or who have young children in their custody.
“Recovering from any life-threatening disease is a lot of work,” Thorp said. “If I had had cancer and got chemo and radiation and surgery, it would be a hell of lot of work. Addiction is just like any other disease. To me, the human capital return on investment is incredible because you positively affect two generations. I think the state should invest more in pregnant women and young children.”
“We can keep a family in residential treatment for a year for just over $30,000. It’s $60,000 to be in prison. If you have two kids in foster care, it costs $60,000 to $70,000 a year – not to mention what it’s like for a child to have a mom in prison.”
To call Hendrée Jones, PhD, a pioneer in this field is akin to saying Michael Jordan was a “decent” basketball player.
Before she joined UNC Horizons as its executive director in 2013, Jones, a licensed psychologist, was a professor at Johns Hopkins University and the director of research at the Center for Addiction and Pregnancy. At the time, while most of the country was reeling from the devastating effects of the crack cocaine epidemic, Baltimore was unique. Baltimore had a heroin problem.
“It was there that I got to understand about methadone and buprenorphine,” two opioid medication therapies, the former approved by the FDA in 1973 and the latter approved in 2002, Jones said. One of the many comprehensive treatment aspects of the work Horizons does is provide pregnant and parenting women with opioid agonist medication – such as methadone and buprenorphine – if that is part of their treatment and recovery plan.
Jones led the first-ever clinical trials of administering buprenorphine in pregnant women. She went on to lead several other clinical trials comparing the outcomes of neonatal abstinence syndrome (NAS) in infants born to mothers receiving methadone or buprenorphine therapies.
But the opioid medication is just part of the therapy, said Jones. It’s the first step on the long road to recovery.
“It establishes a sense of normalcy so we can do the work. You can put up the demographic with baseline characteristics from women in any of the programs across the United States, and we see very similar profiles of women that end up making it to our facilities.
“About 80 percent have had physical, emotional, sexual abuse in their lifetimes. And that continues. I’m a firm believer – and research supports it – that when you address the underlying trauma, it helps address the substance use disorder. So much of it is emotional regulation and learning how to disentangle reaction to trauma versus response to it,” Jones said.
Jones and her team uses trauma-informed care, part of which is just being a steady, reliable force for healing in these women’s lives.
“Our women have been taught from a very early age, ‘you have no worth and what you think and feel does not matter,’” Jones said. “They have experienced lives of childhood and adult physical, sexual and emotional trauma. Trauma and addiction re-wires your brain and radiates pain inside and out. Some of our women have hurt their children, their families, and people in their communities. Horizons works to help women overcome victimhood and loss, and claim their personal power and worth.
“So having to reflect back piece by piece and do the hard work– ‘here’s where I started and here’s where I need to go’ – I don’t think that’s easy for most people. Healing comes from looking at all of those pieces, taking the armor of anger off, and learning new ways of responding rather than reacting. Horizons teaches women ways to emotionally heal and re-wire the brain for healthy behavior and thought patterns. Women discover their inner strength, courage and power to live fully and be the mother they want to be.”
An obstetrics clinic for women with substance use disorders has been at the heart of UNC Horizons since the beginning. Today, in addition to Thorp, Elisabeth Johnson, FNP, PhD, runs a weekly clinic where she sees pregnant women who are using drugs. Johnson is also the director of health services at UNC Horizons.
“On Wednesdays, I have an OB clinic at Weaver Crossing, where we see women with substance use disorders from all over the state,” Johnson said. “We also provide the prenatal care for the all of the women in the program who are pregnant. The other four days a week, I’m at Horizons. I coordinate the healthcare-related issues for our women and their children. I have an open-door policy in my office. Women come by to discuss health concerns or ask questions about medications for either themselves or their children. It’s something different every day."
The clinic, Johnson explained, “really encapsulates what women with substance abuse disorders are dealing with."
“I would say the majority of the women who travel to the clinic on Wednesday are traveling more than one hour to come here for their prenatal care. We get referrals from healthcare providers in the community who know what we do and will send women to us if they identify a substance use disorder. We also hear from women that our clinic has been recommended by a relative or a friend.”
One of the main draws of the UNC Horizons clinic for many women is that it’s one of the only places in the state that offers medication-assisted treatment for pregnant women.
“The important piece that we emphasize is that medication is only part of the treatment process.,” Johnson said. “The idea is that if you can stabilize someone physically, then we can help guide the process of doing the personal work that accompanies treatment and recovery. Dr. Thorp and I are fortunate to have a therapist and a peer support specialist -- someone who is in long-term recovery present in the clinic with us so that we are able to offer a team approach to care. For a lot of women, one of the biggest barriers is the lack of treatment options or very limited treatment options in their home communities.
“When I first started working with Horizons, I spoke to women about trying to find Alcoholics Anonymous or Narcotics Anonymous meetings in their home communities. While these are often good resources I started hearing stories from patients that some of the meetings are not safe because it’s difficult to find gender-specific groups. If you attend a mixed gender group, there’s a chance your former drug dealer is there, your violent ex-partner is there, or you may see people you have used with in the past who are in a different place on their recovery journey. That is not always a safe environment. Many of the women who attend our clinic are socially isolated, and come from areas of the state with high poverty rates, food instability and few resources for treatment.
“The women that we care for are an inspiration. Some of our women have so many barriers in front of them, but yet they come here and they get well and their babies are healthy.”
“As this epidemic of opiate misuse has exploded over the last five to 10 years, we’ve had to learn how to take better care of these babies, so I’ve been collaborating with Horizons for the past six and a half years,” said Carl Seashore, MD, a professor of pediatrics at the UNC School of Medicine and the medical director of the nursery service at UNC Hospitals.
“Neonatal abstinence syndrome, or NAS, is a complicated condition that we’re, unfortunately, seeing more of because of the current opioid epidemic,” Seashore said. “Women of child-bearing age have not been spared in this epidemic. In fact, they’re over-represented in the opiate use and use disorder population. So, if they’re pregnant and using – whether it’s illicitly or in treatment -- their infants are at risk for physiological withdrawal from that opiate substance because it crosses the placenta.”
The babies aren’t acutely ill when they’re born, so at UNC, they stay in the well-baby nursery rather than in the neonatal intensive care unit.
“They don’t generally require being monitored, so we treat them like any other healthy baby with a careful eye on symptoms of withdrawal that typically don’t develop until 48 to 96 hours of life, especially for babies born to women who are in treatment,” Seashore said.
The other benefit of keeping these infants in the well-baby nursery, is that it keeps the mother and the baby together, which is better for the mom and the baby.
Women on a prescribed opiate-replacement can and should breastfeed, Seashore said.
“Breastfeeding can be another motivation to stay in treatment – knowing it’s important to provide breastmilk for your baby and that the baby’s health is dependent on you staying true to your treatment,” Seashore said. “Women in stable treatment have healthier pregnancy outcomes and their babies, in general, do better. They’re less likely to be premature. They’re less likely to need critical care for issues related to prematurity or other birth complications.
“We really started collaborating with the Horizons team to address the question: how can we do better for this population? We started with educating our faculty, our team that takes care of these babies, about NAS, about best ways to treat it, about the importance of having a standard approach to treatment and protocols in place.”
If a baby is at risk of developing NAS, it’s important that the baby be in a calm, quiet, stable environment with mom, free from external noise, light and other stimuli. Keeping the baby with mom so she can have skin-to-skin contact can also help, Seashore said. But if all the non-pharmacologic efforts don’t work, nursery staff will administer tiny doses of morphine, and gradually ween the baby off the opiate that way.
“Cutting the cord is a pretty abrupt ween,” Seashore said.
Horizons prepares expectant mothers for the possibility of NAS and what to do if it occurs.
“Even if mom is cutting back or quitting her smoking, is taking her medications as prescribed, is getting a good night sleep, is eating well, is engaged in treatment, and doing all the things she should with our help, the baby may still withdraw.
“And it’s not her fault if that happens,” Seashore said.
Currently, babies born in the UNC Horizons program have better birth outcomes than the state average. For the past three years, 95-100 percent of mothers who graduated from the residential treatment programs have kept their families intact. Of the graduates, 77 percent have a job by the time they transition back into the community, many of whom come back to work at Horizons.
“One of our best employees at Weaver Crossing is an LPN who has been in recovery for 10 years,” Thorp said. “She went to nursing school at Durham Tech after graduating from Horizons.”
Beyond the statistics, Thorp can summarize Horizons in one sentence: “We’re breaking the intergenerational cycle of addiction and we’re saving lives.”
And now Horizons has the chance to continue this incredible work with more moms and their babies, thanks to the new facility in Carrboro.