Drug addiction and pregnancy: Gundersen PASS program helps moms-to-be succeed in sobriety, parenting

Apr. 29—Susie desperately wanted to stay sober.

From the age of 16, opiates had a hold on her, leading to two incarcerations and extended periods away from her son. She relapsed four times, battling depression and finding herself pulled back into the same lifestyle after each stretch of sobriety.

It was an overdose during her second pregnancy that sparked "a wake-up call," and a team of compassionate health providers that helped her achieve lasting success and a healthy, unified family.

Susie, 28, who requested her last name not be used, is part of the Pregnancy, Addiction and Social Support, or PASS, program at Gundersen Health System. Its comprehensive team approach helps pregnant people actively struggling with addiction or in recovery stay substance free before and after birth. Comprised of an OB-GYN, a registered nurse care coordinator, a nurse midwife and a social worker, the team offers support and internal and community resources, checking in with the patients frequently and managing their mental health conditions, if applicable, with medication and therapy.

"These patients are seen typically more frequently than you would for routine obstetric care," said PASS program lead Dr. Heather Riese, who has specialized training in perinatal mood disorders and substance abuse. "Our goal is using a team approach to develop trust and relationships with them and help them be successful."

An innovative approach

Riese took over the program in 2019, when obstetrician and addiction medicine specialist Dr. Charles Schauberger, who developed PASS in 2012, retired. For the past 8 years, Schauberger has been a member of the Wisconsin Maternal Mortality Review Team, a group that serves to increase awareness of the factors in pregnancy-associated and related deaths, and to compose and promote recommendations for state residents and health care systems to help eliminate preventable maternal deaths.

"One of the key drivers of rising maternal mortality is drug use during pregnancy and the year afterward," said Schauberger. "The increase in drug use in our country and the rise in overdose mortality has been a key driver for the increase in maternal mortality."

A review of 2017-2019 data from maternal mortality committees from 36 states, including Wisconsin, examined 1,018 pregnancy related deaths, for which cause of death was identified for 987. Mental health conditions topped the list, accounting for 22.7% of deaths. Mental health and substance abuse are frequently co-occurring disorders, with the National Survey on Drug Use and Health reported 17 million U.S. adults experienced both in 2020.

In a 2021 report, The Wisconsin Maternal Mortality Review examined pregnancy-associated overdose deaths from 2016 to 2019, finding that in 92% of cases, both mental health conditions and substance abuse were confirmed or probable contributors.

Both mental health and addiction are prevalent issues in the U.S., and participation in PASS has increased in recent years. Currently, there are 30 women in the program, with an annual average of 75 patients. Candidates are identified through initial OB-GYN appointments, where screening questions include substance abuse and mental health concerns. Depending on the response and the patient's medical history, a referral may be made.

Not every referred patient chooses to participate in PASS, and some who have used drugs in the past but are currently sober may decline, "because they don't want to be labeled a drug addict for their entire life."

"We say, 'If you don't feel like you need our services, that's totally fine. We're happy to see you if your feel like you're struggling or you need help connecting with behavioral health services," said Riese. "But the stigma, unfortunately, is always there. We even see it in other medical providers. There's just not as much knowledge about these patients, and they can be seen as difficult. But these are patients that we can really help and improve their lives and their babies' lives."

If the patient prefers, the team will help set them up with a primary care provider, with the family medicine team keeping PASS staff posted on progress.

"We have great teamwork here at Gundersen to really make sure these patients don't fall through the cracks," said Riese.

The team, which has started seeing more word-of-mouth recommendations, finds many women choose to utilize the program during subsequent pregnancies, with the comfort and rapport reducing their chances of backsliding on their progress.

Riese blocks off portions of her schedule to accommodate PASS patients who need to be seen outside of regular appointments, with either herself or nurse midwife Jessica Hamilton making themselves available. Social worker Chrystal Johnson helps patients, many of whom are homeless, secure housing or shelter, food and free childbirth and parenting classes.

Riese may prescribe medication for mood disorders or buprenorphine, a prescription drug used to treat opiate use disorder. The team also helps secure any other services necessary for the patient's overall health and care, from therapy or psychiatry appointments to dental cleanings.

"The old saying is, 'It take a village to raise a child,' and with the PASS clinic we start building that village right away," Johnson said.

The team also works with incarcerated patients and helps those who need more intensive treatment enter a residential program.

"We're not here to judge," said Riese.

The struggle for success

Around 60% to 80% of those with substance abuse disorder will relapse within a year, according to the National Institute on Drug Abuse, and when Susie left her first inpatient treatment facility at age 19 her sobriety lasted only five months.

"I went right back to the same life," Susie said.

She was actively using opiates when she became pregnant with her first child, and was jailed on drug-related charges near the end of her second trimester.

With the help of a second inpatient program, she stayed sober until her child was 11 months old. But she soon found herself incarcerated again, spending a year in prison. Just 12 months later, she was back in prison for another year.

During her incarcerations, Susie's child lived with family, and, ashamed of her drug use, she had little contact with them outside of supervised parental visits.

"When you are living in that lifestyle, around people who are using and having those connections, it's hard," Susie said of her relapses. "I was living in the same area and running into the same people. I knew they didn't care about me and they weren't my friends, but I was lonely. It's hard to make all new connections. And going to AA meetings — that can be scary going alone."

Starting a new life after being released proved nearly impossible.

"I was using when I went to jail and I wanted to be clean, but when you get out and you're homeless or living in a trap house, and you have no job and might not have a connected phone, where do you go?" said Susie. "There are shelters, but a lot of them are surrounded by drugs. You might want to be sober, but it's hard when there is one obstacle after another in the way."

When Susie left prison for the last time in 2019, she found herself in an abusive and controlling relationship, turning back to drugs. She became pregnant and went to Gundersen for care, where the team worked to find her resources and tried medication assisted treatment, which combines medications with counseling and behavioral therapies. But being around drugs proved too tempting, and at four months pregnant, Susie overdosed.

"It was a wake-up call," said Susie. "I knew if I didn't get sober I would be leaving the hospital without my baby, and that was something I couldn't wrap my head around."

The reality of relapse

The success rate for mothers staying healthy during pregnancy and being able to take their children home — a report to child protective services is mandated in cases of prenatal drug exposure — is "a mixed bag," said Riese.

"I feel like overall our patients really do quite well when we are able to get them connected and start treating their mood disorders, regardless of if they're successful with their sobriety or not," said Riese. "Patients are very motivated to get to be able to become sober and maintain that sobriety. Obviously, patients are at different places in their sobriety journey in pregnancy, and for some this is the 10th time they've tried to become sober before they're successful."

Patients, said Riese, are generally very honest about their substance use, and will admit when they have "slipped up."

"And then we say, 'OK, thanks for letting us know.' And then we move on," said Riese.

The PASS team is upfront about the possibility of child protective services being involved, whether it's through the development of a safety plan, temporary loss of custody or other actions. Demonstrating a commitment to the PASS program may be have a positive influence on the outcome.

Babies who have been exposed to opiates in utero go through withdrawal, called neonatal abstinence syndrome, and the PASS team works closely with the pediatric hospitalist staff to ensure the child is healthy prior to release. The babies are kept in the hospital longer than other newborns and able to be in the room with their mothers. For moms who have been sober for at least 30 days, breastfeeding may be encouraged.

While many PASS patients suffer from opioid addiction, methamphetamine laced with fentanyl has become the primary substance seen in patients.

"We have patients that have no idea — they think they're using pure meth and then it comes back positive for fentanyl," said Riese. "We have patients that actually have used marijuana that had fentanyl in it."

Methamphetamine has proven the harder addiction to beat, as it can alter the brain chemistry for up to 2 years after halting usage, Riese said. In addition, suboxone is not effective with non-opiate drugs.

"Methamphetamine is just a challenging, challenging substance to treat," said Riese.

Until recent years, said Riese, there has been "really poor reporting" of maternal death rates related to mood disorders and/or substance abuse, and historically the rate has likely been far higher than believed. With more awareness now of mental health concerns, perinatal and postpartum depression, psychosis and suicide, and increased access to resources, Riese is hopeful for improvement.

However, Relapse rates are higher postpartum, as for some the "big motivator of staying sober for baby is no longer there when they're not pregnant," said Riese. Postpartum depression or untreated mental health concerns can also be a barrier to sobriety, and with the drug crisis ongoing patients have died due to either overdose or homicide related to drugs.

"It is the most devastating thing to see this patient that you took care of and was doing well ultimately die," said Riese. "It is a horrible thing for everybody involved."

Patients have also had the father of their child or another close relation die from drugs, said Johnson.

"They might not be the one to overdose, but they're still being impacted somehow by that overdose death," said Johnson. "She's now having to administer Narcan to someone who's overdosing as she's eight months pregnant."

Seeing those who so desperately "want to be clean and want to do the right thing for their baby" wrestle with the "beast that is addiction" is the most challenging part of her job, Johnson said.

"We want them to be successful. When we see them postpartum and they are happy and clean and doing well and loving on their baby, it's amazing to see."

Resilience and commitment

When Susie entered the PASS program, she was "really significantly struggling with addiction," Riese said. At one point, the team requested a welfare check when Susie became unreachable. Actively using at the time, Susie felt their "genuine concern."

"I could have overdosed," Susie said.

To help Susie get on track, the PASS team admitted her withdrawal support in the hospital before Susie entered a residential treatment facility for around five weeks. Susie was prescribed suboxone and upon her return frequently met with Riese, Johnson and Hamilton, with RN care coordinator Heather Bushman also involved in her care.

"It wasn't just, check your vitals, 'Any questions? No? See you next time,'" said Susie. "I felt very comfortable with them and could trust them. They always told me how proud they are of me and to keep going."

Susie committed to her sobriety, attending AA meetings and becoming active in the recovery community. She was sober when her baby was born in January 2022, the infant completely healthy and not suffering any withdrawal symptoms.

"The Gundersen team was like my family. If I didn't have people pushing for me I wouldn't be here today," said Susie. "Anytime I needed anything, they'd help me find resources."

Post-pregnancy, PASS remains involved in patients' lives. New moms can enroll in GunderKids, a program designed for families coping with substance abuse, mental health, domestic violence or other barriers to a healthy household. Newborns are seen 17 times in their first 12 months, and staff check in with parents on access to necessities, sobriety, child development, stressors, challenges and more. The close evaluation and parental education increases vaccination rates and overall measures of health as the child grows, while also reducing the risk of child maltreatment.

"Part of the PASS clinic is making sure that it's not going from this super supportive prenatal experience to just, 'OK, you're done, you had the baby, goodbye,'" said Johnson. "It's making sure that I'm getting them connected to those programs in the community so they still have that social worker, they have that medical connect, all of those things out in the community as well or through the clinic. They're going to be seen for whatever it may be."

Added Riese, "It's amazing how resilient these women are. When they get the support they need, they are able to improve their lives and their kids' lives and ultimately help their overall community."

As part of her responsibility to her sobriety, Susie moved back to her hometown around an hour outside La Crosse, surrounding herself with family and sober friends and away from triggering people and places. Engaged, Susie became pregnant again several months ago and continues to see the PASS team through her third pregnancy.

"She is in a completely different place to when we first saw her," said Riese. "She is doing fantastic and rocking it."

Due in about a month, Susie has a job, is attending school and is an active mom to her two kids and her fiance's child. Her six-year-old, who struggled with behaviors and emotions while Susie was incarcerated and battling addiction, is thriving with the structured schedule and stable household Susie and her fiance have created.

"She is unique in the sense that she has an internal drive to get things done herself, which is amazing," Johnson said. "She knows that we are here for support and to assist her when she hits road bumps."

Susie hopes to wean off suboxone in the future, but for now the medication is helping her be a "productive member of society," she said. She has been sober for close to a year and a half.

"Susie is the success story we hope to see with all of our patients," said Johnson. "She continued to push through things that were hard for her because she trusted in the team and that her efforts would have a positive outcome — which they have."

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