Analysis Maternity and Birthing

Stigma Surrounds Addiction Treatment for Pregnant People in Indian Country

Mary Annette Pember

“If I could save someone 100 times, I would," said one advocate. "Maybe after that 101st time they might be ready to get help. If they die, they’ll never get that chance."

“Hey, guess what? I’m pretty badass and I can do this!” a client recently said to Julie Williams, program director of the Maternal Outreach and Mitigation Services (MOMs) program.

Based on the White Earth Ojibwe Reservation in North Minnesota, the MOMs program provides culturally appropriate addiction services to pregnant Native people. In addition to treatment and mental health services, clients receive buprenorphine, a drug used in medication-assisted treatment, to prevent opioid withdrawal during and after pregnancy.

Williams’ client, who had been receiving medication during and after her pregnancy,kept relapsing, using narcotics once every three months or so,” she told Rewire.News. “I confronted and questioned her.”

She said to Williams, “I’ve never gone more than three months without using; it’s so scary to believe in myself when everyone has told me I can never be more than an addict.”

That admission was a turning point for the woman. She has now been sober for more than one year, according to Williams.

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Despite being medically approved for use by pregnant people addicted to opioids, buprenorphine and medication-assisted treatment, or MAT, has been controversial both in Indian Country, where the opioid epidemic has hit especially hard, and beyond. But for advocates, the medication is a much-needed resource, which is why some are lobbying for more investment in tribal nations through a fully funded Indian Health Service (IHS).

Anything less than that creates an endless cycle of deferral and opioid dependency, explained Sam Moose, the National Indian Health Board’s treasurer and area representative in Bemidji, Minnesota, in a written testimony to the U.S. Senate Committee on Indian Affairs in March. Moose argued that Congress’ historic refusal to fully fund the IHS has forced the agency to defer patient care and push more tribal members toward prescription opioids to treat health conditions that would otherwise have been treated with more expensive therapies.

The data on opioid dependency in Indian Country bears that out. According to the Minnesota Department of Human Services, Native American women in the state are 8.7 times more likely than non-Hispanic white women to be diagnosed with opioid dependency or use during pregnancy. Native American infants are 7.4 times more likely to be born with neonatal abstinence syndrome (NAS), a group of symptoms related to sudden discontinuation of addictive substances.

The rate of drug-related deaths among Native Americans and Alaska Natives is nearly twice that of the general population, according to data from the Indian Health Service. The Centers for Disease Control and Prevention (CDC) reports that in 2015, Native Americans and Alaska Natives had the highest rates of death from drug overdose of any ethnicity.

Tribal communities, including White Earth, have tried a number of methods to address the burgeoning rates of opioid addiction on the reservation. Indeed, the problem continues to overwhelm often already over-extended tribal health and judicial infrastructures. Some tribes rely primarily on their justice systems and criminalize drug users; some have turned to traditional sanctions such as banishment.

In The Breach, a Rewire.News podcast, host Lindsay Beyerstein recently examined laws among some tribes that allow for incarcerating pregnant people who use drugs or alcohol.

Even while testing out such methods, some tribal leaders, just like citizens in mainstream society, have remained reluctant to support medication-based treatment programs for pregnant people or drug users in general.

Regarding pregnant people who use drugs, people may have bought into the “crack epidemic” stigma reported by media in the 1990s. So-called crack babies were described as irreparably damaged, both physically and mentally, by pregnant women who used drugs during pregnancy. Subsequent studies have failed to bear out these claims.

In an interview with the Retro Report, Dr. Claire Coles of Emory University’s School of Medicine said of the national scare, “There are a whole lot of people who think if you can scare people sufficiently about something, it’s better than actually telling them the truth because fear will keep them from doing bad things.”

In her research Coles found that prenatal use of tobacco and alcohol caused the most severe damage for infants.

Williams has heard many people criticize the use of naloxone, a medication that rapidly reverses opioid overdose, to save users who overdose.

“I ask them, ‘What if it was your child? Wouldn’t you want to save her every time that you could? If it’s not your child, do you really want your friends and neighbors to mourn the loss of their child?””

“If I could save someone 100 times, I would. Maybe after that 101st time they might be ready to get help. If they die, they’ll never get that chance,” she said.

Harm Reduction

Medication-assisted treatment is part of harm-reduction addiction programs. Unlike total abstinence addiction treatment strategies, such as 12-step programs, the harm-reduction philosophy accepts that a level of drug use may continue for clients and aims to reduce harmful consequences.

Regarding pregnant people, several major medical organizations agree that exposing newborns to the risks of opioid withdrawal through MAT treatment is far outweighed by the likelihood of fatal overdose when a pregnant person goes without treatment or attempts abstinence, according to an article published by the Pew Trusts.

A pregnant person with an addiction who suddenly stops using opioids puts herself at risk for miscarriage and stillbirth.

Pregnant people who use drugs are so stigmatized by society, however, that they may be too fearful or ashamed to seek treatment, according to Williams.

“Pregnant drug users are judged far more harshly than others who use. People may look at them and say, ‘How dare she!’ ‘How awful is she!,’” Williams said.

Some may avoid prenatal care altogether for fear of sanctions by law enforcement and health-care professionals, as reported by Rewire.News in a previous article about the high rates of maternal and infant mortality among Native Americans.

“Judgment is out the door here at MOMs. We’re here to care for them while holding them accountable for their recovery,” said Williams. “In addition to taking their medication, [clients] have to participate in mental health and treatment programming, as well as life skills training.”

Women who relapse, however, are not automatically removed from the program. As mandated reporters, MOMs staff must report drug use to child welfare authorities. But if the clients “are actively seeking help, we think it’s better that we continue seeing them every day rather than having them leave,” Williams noted.

“We call people on their B.S. here; we confront them and work with them to find out what’s behind their relapse,” she added.

Since the program began on the White Earth reservation in 2015, MOMs has had 32 graduates and now has a second off-reservation location in Minneapolis.

“Rather than victimize, we help to empower. We have a community of [people recovering from addiction] who can talk and support each other; we have a family of moms who breastfeed their babies and maintain that bond with their families,” Williams said.

“Our clients are building a sober community for themselves. Since our communities are so small, even a group of five to six sober people can set an example and inspire others to get help.”

Gwayakobimaadiziwin, or “the right kind of life,” is another grassroots organization helping to build community among people who use drugs. Most of Gwayakobimaadiziwin’s clients are women; some are pregnant, many are mothers. Philomena Kebec of the Bad River Ojibwe tribe in Wisconsin and Aurora Conley, another tribal member, formed the volunteer organization in 2015 in response to suffering and death in their community from opioid addiction. Using donated equipment and funds from a series of small grants, they created a needle exchange program and provide disposal services and overdose prevention training free of charge.

Philomena Kebec of the Bad River Ojibwe tribe. (Mary Annette Pember)

Kebec and Conley grew disheartened as they saw friends and family suffer and die because of lack of resources or support.

“I’ve heard some of our tribal members say we should not treat narcotic overdoses with naloxone. We should just let those people die since they’ve chosen to abuse narcotics,” said Kebec.

“A lot of people in our community are injecting drugs; we have to meet them where they’re at by providing information, safe places, and resources for them and their families in order to reduce harm they do to themselves and others,” Conley said.

“Helping each other, harm reduction, is the traditional Native way. We wouldn’t banish someone if they had a disease like cancer; addiction is also a disease,” she added.

Unfortunately, harm-reduction treatment such as MAT is difficult to find for Bad River members; the Bad River Health and Wellness Center, a tribally run Indian Health Service clinic, only offers 12-step, abstinence-based treatment. Although Indian Health Service allows its physicians and some health-care professionals to prescribe buprenorphine, the local clinic does not offer these services.

Moose, in his testimony to the Senate committee earlier this year, pointed out that situations like this are common among many tribes. Communities lack the resources to keep up with the latest training practices for health-care providers.

As sovereign entities, tribes may not be included in state public health initiatives, such as those created by the 2016 CURES Act’s $1 billion in federal funding to states for fighting the opioid crisis. Under its current status, tribes have no direct access to the funding available under the act and must depend upon the discretion of states to include them in programming. In March, U.S. Rep. Markwayne Mullin (R-OK) introduced HR 5140, the Tribal Addiction and Recovery Act (TARA), which would grant tribes direct access to CURES Act funding. TARA has been referred to the Subcommittee on Health.

The IHS is the primary federal agency providing health care to tribes. The agency delivers services directly at IHS facilities and through tribally contracted health programs and services purchased from private providers.

In his testimony Moose wrote,The Indian Health system is chronically underfunded, understaffed and overextended. Limited tribal and IHS public health and health care resources have been further inundated by this highly deadly and superbly costly epidemic.”

Moose noted that in fiscal year 2017, national health spending was $9,207 per capita while IHS spending was limited to $3,332 per patient. He testified that due to limited funding, nearly 80,000 Purchased/Referred Care (PRC) services were denied in fiscal year 2016.

“The federal government must take concrete action to ensure Indian Country has the tools it needs to address opioid abuse and heal tribal communities,” Moose wrote.

In the meantime, however, tribal communities are taking action on their own in any way they can; one of the benefits of being a sovereign entity is that a tribe can create its own internal judicial and social service laws and practices.

“Tribes are all over the board in how they are trying to deal with addiction in their communities. Some have taken a more criminal approach, and some are seeing it as a public health issue,” said Adam Fairbanks, a public health consultant for tribes.

Fairbanks of the White Earth Ojibwe tribe helps tribes set up collaborations to help create reimbursable health-care services that cover treatment for addiction, including MAT.

“Many tribes are just trying to get questions answered about what they can do to address addiction,” he said.

Julie Williams in one of the client meeting rooms at the MOMs Minneapolis location. (Mary Annette Pember)

Since White Earth started its MOMs program, the tribal court no longer relies on the civil commitment option to force pregnant people who use drugs to enter treatment.

“The courts don’t need to use that anymore; addicted pregnant people now come forward on their own for treatment at MOMs,” Williams said.

It took a lot of hard work, however, to get the community on board with MOMS’ harm-reduction treatment model.

Williams and her co-workers hosted family nights and offered big meals for the community during which they could learn more about the program their relative was working on.

“Family members have thanked us. Parents have told us they notice a difference in their daughter, she now has purpose,” Williams said.

MOMs leaders have also created relationships with doctors and hospitals in the area, ensuring that clients following the program aren’t reported to police and that mothers aren’t separated from their babies and are allowed to breastfeed.

As reported by Rewire.News, experts support breastfeeding and keeping mother and baby together for infants with neonatal abstinence syndrome symptoms.

“Some medication may be passed through breastmilk, but MOMs has found that the protective factor of breastfeeding far outweighs the risks. Even if baby has withdrawal symptoms they are very mild; baby is comforted by mother,” said Fairbanks.

At MOMs, clients’ intimate partners can join them in getting treatment. Parents can also bring their children along to treatment sessions.

“We’re trying to create a base for our clients to go home and be successful,” Williams said.

And for its part, Gwayakobimaadiziwin holds monthly meetings within the community. We provide a meal, sharps containers for used syringes and needles, HIV testing, help with treatment or social service referrals,” Kebec said. “We are building community by helping each other.”

Volunteers also bring supplies to clients’ homes if needed. “We find that the [people who use] help each other; they provide moral support, celebrate small victories,  and keep each other safe,” Kebec said.

Most of Gwayakobimaadiziwin’s clients have a history of trauma, according to Kebec. “That’s why it’s important to be non-judgmental; the women already judge themselves so harshly,” she said. In fact, the most important element of the organization’s services is an atmosphere of non-judgment.

Although the tribe doesn’t currently offer MAT, several users treat themselves with buprenorphine that they obtain illegally, according to Kebec. “Nobody wants to be an addict,” she noted. “With buprenorphine at least they can function and have a life, take care of their children.”

Volunteers at Gwayakobimaadiziwin are also working on creating a survey of users needs. “Most of the big programs aimed at addressing drug addiction don’t seem to include input by users themselves,” Kebec noted.

“Abstinence based 12-step treatment doesn’t seem to work for meth and heroin [abuse],” said Conley. “Our people need wraparound services that help with housing, food, and keeping police off their backs. Going to jail all the time doesn’t help them.”

“The strength of traditional Native culture has its roots in community,” Kebec pointed out, echoing Williams, who said that while she can’t say for sure that harm reduction is a traditional value, she thinks the philosophy is influenced by Native culture and ways.

“Most of the harm-reduction programs we see have a common beginning; they start with a small group of grassroots folks dedicated to community health and preserving and revitalizing Indigenous life and ways,” Fairbanks said.

“Our ancestors have overcome so much shit,” Conley said. “We are warriors and we can survive this if we help each other.”

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