oversight

Drug Exposed Infants: A Generation at Risk

Published by the Government Accountability Office on 1990-06-28.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

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                  Testimony
GAO


For Release         DRUG EXPOSEDINFANTS:
on Delivery         A Generation    at Risk
Sxpected at
1O:OO a.m. EDT
Thursday
June 28, 1990




                    Statement of Charles A. Bowsher
                    Comptroller  General of the
                      United States
                    Before the
                    Committee on Finance
                    United States Senate




GAO/T-HRD-90-46
                                                      GAO Pora 100 (12/87)
                                 SuMMARy
              PN DRUG-EXPOSEDINFAmS* . A -RATION            AT RISK

In 1988, some 5 million       women in the United States reported using
illicit   drugs.   Drug use during pregnancy can cause major health
problems for both the mother and infant.          Drug-addicted   pregnant
women are in need of prenatal       care and drug-treatment     services,    and
many drug-exposed     infants   need intensive  health care services.        In
addition,    the costs of the continued care of these children          to the
health care and social services        systems will be high.
TO study the problem of drug-exposed        infants,   GAO visited     10
hospitals   in five cities   that primarily     served a high proportion    of -
persons receiving    Medicaid and other forms of public         assistance.
Data from the records at these hospitals         and from the National
Hospital   Discharge Survey were analyzed.         Leading neonatologists,
social welfare authorities,      and drug-addicted     pregnant women were
also interviewed.
GAO found that:
-- Tens and perhaps hundreds of thousands of drug-exposed    infants
   are born each year.    The exact number is unknown, in large part
   because hospitals   are not identifying many of them.
--   Drug-exposed infants    need medical and social services   that will
     cost billions  of dollars   in the years to come. One estimate of
     the cost of services    for a drug-exposed infant who is
     significantly  impaired is $750,000 for the first     18 years of
     life.
--   Despite the demonstrated ability  of prenatal    CL-= ;nd drug
     treatment  to reduce the number of infants   affected  by drug abuse,
     less than 11 percent of women in need of drug treatment     are
     estimated to receive services because of a shortage of programs.
--   Less than 1 percent of funds under the federal  anti-drug strategy
     is targeted  specifically at drug treatment for women. For drug-
     addicted pregnant women, the percentage of federal expenditures    is
     even less.
The problem of drug-exposed   infants   calls for an urgent national
response.   Expanding drug treatment    services might reduce the number
of drug-exposed  infants  and alleviate    some of the social problems
associated  with their care.
With additional     federal    funding the large gap between the number of
women who could benefit        from drug treatment  and the number of
residential     and outpatient     slots available could be reduced.    GAO
believes    that this commitment of funds could save money in the long
term as well as improve the lives of future generations          of children.
                                                        .



Mr. Chairman and Members of the Committee:


We are pleased             to be here today                 to discuss       our report       on the
growing         and costly        problem       of substance-abusing               mothers         and their
infants.l              At your request          we have reviewed              the extent          of the
problem,         its     impact    on the health                and social     welfare      systems,         and
the availability                of drug treatment                and prenatal      care to drug-
addicted         pregnant        women.        In brief          we found that:


-0
       Tens and perhaps               hundreds          of thousands          of drug-exposed
       infants           are born each year,                 but the exact        number is
       unknown because hospitals                        are not identifying               many of
       them.


-0
       These infants              constitute           a growing       national         problem
       necessitating              medical       2~2 '1          la1 services      that     will      cost
       billions           of dollars        in the years            to come.       One estimate             puts
       the cost           of services          for     drug-exposed          children      who are
       significantly               impaired          to be as high       as $750,000          for     the
        first          18 years     of life.


 -0
       Despite           the demonstrated              ability       of prenatal         care and drug
       treatment           to reduce the number of infants                        affected          by drug
       abuse,           there     is a serious          shortage       of drug treatment              capacity


lDruq-Exnosed   Infants:                  A Generation             at Risk      (GAO/HRD-90-138,
June 28, 1990).
                                                            1
         for     pregnant        women.          of the estimated                280,000         pregnant     women
         nationwide          in need of treatment,                    less      than      11 percent         receive
         care.


es
         Less than         1 percent            of federal       funds       allocated            under     the
         federal      anti-drug           strategy         is Specifically                targeted        at drug
         treatment         for     women.         For drug-addicted                pregnant         women, the
         percentage          of federal           expenditures           is even less.


In my testimony              today     I will        be addressing               these     issues.


BACKGROUND


One of the most troubling                        aspects       of our current              drug epidemic            is
the number of women who are using                              drugs.           In 1988,         some 5 million
women reported             using      illicit        drugs,         including        cocaine,         heroin,
PCP, and marijuana.                   The use of drugs                during        pregnancy         is of
particular         concern         because they            affect       both the mother               and the
developing         infant.           Cocaine,        for    example,          may cause constriction
of blood         vessels         in the placenta            and umbilical                cord,     which     can
result         in a lack         of oxygen and nutrients                     to the fetus,            leading       to
poor     fetal     growth         and development.                  Some infants           prenatally
exposed to cocaine                 have also         suffered          from a stroke              or hemorrhage
 in the areas         of the brain               responsible           for      intellectual          capacities.




                                                           2
Federal     support        for     treating           drug addicts        is addressed                 in the 1990
National      Drug Control              Strategy.2            Under this        plan         over 70 percent
of an estimated            $10.6 billion               in fiscal      year      1991 would be spent                   on
drug-supply-reduction                   activities;           the remainder            would be targeted
at reducing         the demand for              drugs.         Approximately            $1.5        billion       would
be spent      on drug treatment,                  with     over half         of the          federal          funds
provided      through          block     grants        to the states          administered               by the
Alcohol,      DNg     Abuse and Mental                   Health    Administration.3                    The states
are required         to set        aside      at least         10 percent           of these          funds to
provide      drug-abuse          prevention            and treatment          for      women.


Moreover,      two federal-state                  health       programs       are potentially
available      to pregnant              women who abuse drugs.                      First,       the Maternal
and Child      Health          Services       block       grant     program         (MCH) provides
grants      to the states              for   health       services      to low-income                 persons
with     the intention            of reducing            infant     mortality          and morbidity,
frequent      consequences              of drug abuse by pregnant                      women.           Second,
the Medicaid         program,           which provides             federal      financial             assistance
to the states            for     a broad      range of health             services            for      low-income
persons,      requires           coverage       of low-income           pregnant             women.           Those
pregnant      drug abusers              who have low incomes could                       qualify          for
services      under either              program.



2The Office of National   Drug Control Policy,    responsible   for
developing  an annual national  anti-drug  strategy,    was established
in 1988.
3A component of the Department                           of Health      and Human Services.
                                                          3
In response        to the          issues      raised      in your         request,     we interviewed
leading       neonatologists,               drug treatment           officials,             researchers,
hospital       officials,            social      welfare        authorities,          and drug-addicted
pregnant       women.         We analyzed           data       from the National              Hospital
Discharge       Survey        and reviewed           medical        records        at 10 hospitals;               two
in each of five              cities--Boston,              Chicago,         Los Angeles,             New York,         and
San Antonio.           The 10 hospitals,                  which accounted             for     about      45,000
births      in 1989, primarily                 served      a high proportion                 of persons
receiving       Medicaid           and other        forms of public               assistance.            In
addition,       we interviewed                officials         at 10 hospitals              that     served      a
high     proportion          of privately           insured        patients.


THE NUMBEROF DRUG-EXPOSED
INFANTS IS HIGH


Identifying         infants          who have been prenatally                     exposed to drugs              is
key to providing              them with          effective         medical        and social
interventions          at birth          and as they            grow up.          At present,          however,
the actual        number of drug-exposed                       infants      born each year             is
unknown.         The two most widely                  cited      estimates         are 100,000           and
375,000.         Neither           of these      estimates         is based on a national
representative              sample of all           births.


A major       reason        that     the total        number is unknown is that                       hospitals
do not systematically                   screen      and test         for    maternal         drug use.



                                                           4
Hospital         officials          acknowledged            to us that          under      their      current
procedures,          many drug-exposed                  infants       are not being               identified.


In reviewing            maternal         and infant           medical     records          at only          10
hospitals,          we found approximately                     4,000     infants         born      in 1989 who
had been prenatally                   exposed to drugs.                 However,          the range             in the
number of drug-exposed                      births      across       hospitals          was wide--from                     13
per thousand            births        at one hospital               to 181 per thousand                    at
another.           This      variation          may be associated               with      the procedures
hospitals          use to detect             drug use during             pregnancy.               The hospital
with     the lowest           recorded          incidence          of drug-exposed               infants         did not
have a protocol               for     assessing         drug use during                pregnancy.               At the
other      nine,      protocols           to identify          drug-exposed             infants       were based
primarily          on whether          the mother           told     hospital          staff      she used drugs
and whether           the baby exhibited                 drug withdrawal                symptoms.


However,         these       screening          protocols          miss many drug-exposed                       infants.
Women are reluctant                   to admit         they    use drugs         for      fear     of being
incarcerated              or having         their      children        taken     away.           In addition,
many cocaine-exposed                     infants       display       few overt          drug withdrawal
signs.          Some will           show no signs           of drug withdrawal,                   while         for
others         withdrawal           signs    will      be mild       or will       not appear until
several         days after           hospital         discharge.         The visual              signs      of drug
exposure         vary      from severe              symptoms to milder             symptoms--such                     as
irritability              and restlessness,              poor feeding,             and crying--which
would not lead to a suspicion                            of maternal          drug use unless          urine
testing      is conducted.


In cases where more rigorous                        detection          methods have been used,
many more drug-exposed                    infants         are identified.            A 1989 study               at a
large     Detroit        hospital         found that             600 drug-exposed          infants         (or 8
percent      of total         births)          were identified               when self-reported             drug
use by the mother                was the basis             for     screening.        However,         a more
sensitive        test     for     detecting          drug use found the incidence                      of drug-
exposed infants            at this            hospital       to be 42 percent,             or nearly            3,000
births,      in 1989.


DRUG-EXPOSEDINFANTS HAVE MORE
HEALTH PROBLEMSAND HIGHER COSTS


In our review            of medical            records       at these         10 hospitals,          we also
found that          mothers       of drug-exposed                 infants      are more likely             to
receive      little       or no prenatal                 care.      Their      infants     have
significantly            lower        birth     weights,          are more likely          to be born
premature,            and have longer             and more complicated               hospital         stays.


During      my recent         visit       to a neonatal             intensive       care unit         in
Boston,      I personally              observed          the tragedy          of infants      suffering
from the consequences                    of their         mothers'          drug addiction.           These
infants      required           the assistance             of complex high-technology
medicine        to overcome the effects                         of drugs.        Such treatment,            and

                                                            6
the extended          length     of hospitalizations                     for     many, translate               into
costly      care,     which     is predominately               paid       for      by public          funds.          In
fact,      our study       revealed       that      charges        for     these          infants       were up to
4 times      greater       than those        for     nonexposed                infants.           Although      the
long-term       physical        effects      of prenatal            drug exposure                   are not well
known,      indications         are that         some of these                 infants      will      continue         to
need expensive          medical       care as they grow up.


IMPACT ON SOCIAL WELFARE
SYSTEM IS PROFOUND


In addition          to the costly          medical         treatment,             some infants              remain
in the hospital            because their            parents        either          are unwilling              to care
for     them or they        have been determined                   by child           welfare         authorities
to be unfit          to provide       for    their         care.      These "boarder                  babies"
often      are placed         in foster      care.


Through      our medical         records         review,       we found that                a substantial
proportion          of drug-exposed          infants         did not go home from the
hospital      with     their     parents.           Of the 4,000                infants       we identified
as drug exposed,              30 percent,          or 1,200,        were placed               in foster         care.
The estimated          yearly     cost      of foster          care       for      these      infants         alone        is
$7.2 million.


The infants          who are discharged              from the hospital                     with      their     drug-
abusing      parents       are at risk           of abuse and neglect.                        The child

                                                       7
protection        agencies         in the five            cities      in our survey           all     reported
that    they     are investigating                a growing          number of child           abuse and
neglect        cases due to substance                 abuse by the parents.                    These
investigations           often       lead to foster                care placement.            Hospital
officials        are also        seeing     many children                 from drug-abusing                families
admitted        and readmitted            to their         hospitals         suffering        from physical
neglect        or injury.


City    and state        officials         we contacted              told    us that      prenatal           drug
exposure        and drug-abusing            families            are placing         increasing         demands
on their        social      welfare       systems.             Although      they     perceived            the
problem        to be growing,           most could             not provide       statistics           on the
numbers of drug-related                   foster      care placements.                 Officials            in New
York,       however,     estimate         that     57 percent             of foster      care children
come from families               that     allegedly            are abusing       drugs.


Because the estimated demand for foster care nationwide increased
     .
29 percent from 1986 to 1989, there is concern as to whether the
system can adequately                   respond     to the needs of drug-abusing
families.          Specifically,           problems            have been identified                 with     the
availability           of foster         parents      who are willing               to accept         children
who have been exposed to drugs,                           the quality          of foster        care homes,
and the lack           of supportive             health        and social       services        to families
who provide         foster       care to these                children.




                                                          8
In addition          to concerns         about      the safety           and care         of drug-exposed
infants,        many may also           have long-term               learning      and developmental
disabilities.             Without       intervention            we would expect             major      problems
in school         and high         dropout      rates.         The cost         of helping         these
children         overcome the effects               of drug exposure               will     vary      with      the
severity         of disabilities.


We recently          visited        a pilot      preschool           program      for     mildly      impaired
drug-exposed            children       in Los Angeles.                To minimize          the effects             of
prenatal         drug exposure,          the program            provides         an enriched
environment,            smaller      classrooms,           and more direct              attention        to the
children         at an annual         cost      of $17,000           per child.           On the other             end
of the spectrum,               the Florida         Department           of Health         and
Rehabilitative            Services       estimates            that     for     drug-exposed          children
who show significant                 physiologic           or neurologic           impairment,             total
service         costs    to age 18 could            be as high               as $750,000.


LACK OF DRUG TREATMENTAND PRENATAL
CARE IS CONTRIBUTING TO THE NUMBER
OF DRUG-EXPOSEDINFANTS


To address          the problems             associated        with     the growing          numbers of
drug-exposed            infants,       pregnant          women who use drugs               need to be
offered         comprehensive          treatment          services.            Recent studies          have
found that          significant         positive          effects       in the health              of the
infant     can be achieved              if     the mother            is able     to stop drug use

                                                          9
during        pregnancy.           The risk        of low birth              weight     and prematurity
that     often         require     expensive         neonatal         intensive         care are minimized
by treatment             services       and prenatal           care.


However,         in the five           cities      we visited,          drug treatment                 services
were either             insufficient            or inadequate          to meet the demand for
services         for     drug-addicted            pregnant      women.              Many programs         that
provide        services          to women, including                 pregnant         women, have long
waiting        lists.          In fact,         nationwide,          drug treatment             services         are
insufficient.                 A 1990 survey          conducted         by the National                 Association
of State         Alcohol         and   DNg       Abuse Directors              estimated         that     280,000
pregnant         women nationwide                were in need of drug treatment,                           yet    less
than      11 percent           of them received              care.


In addition             to insufficient            treatment          capacity,         some programs             deny
services         to women because they                  are pregnant.                 A survey         of 78 drug
treatment         programs          in New York City             found that            54 percent          of them
denied        treatment          to pregnant         women because of fear                  of legal
liability.              DNg      treatment        providers          fear     that     certain         treatments
using        medications          and the        lack   of prenatal             care or obstetrical
services         at the clinics              may have adverse                consequences          on the
fetus.


Other        barriers         to treatment          exist.       Pregnant            addicted     women told
us that        the      lack     of child        care services              often     made it      difficult
for     them to seek treatment.                      These women may also                  have additional

                                                         10
needs-- such as parenting,                    education,         and nutritional             guidance--
that     are not provided                in most treatment             programs.        Another         barrier
to both drug treatment                    and prenatal         care      is the potential             for
criminal        prosecution.              The increasing          fear     of incarceration                  and of
losing      their       children         to foster      care     is discouraging            pregnant           women
from seeking            care.


'Many health        professionals             believe        comprehensive          residential              drug
treatment        that     includes         prenatal      care services             is the best
approach        to helping          many women give            up drug use during                pregnancy.
This     also    assures         the developing          infant        the best      chance of being
born healthy.             However,         such programs          are scarce.           Massachusetts
officials        told     us that         the lack      of residential             treatment         slots      was
a   major    problem.            Only 15 residential              slots     are available             to
pregnant        addicts         statewide.        California           hospital      officials
reported        a similar          problem.       Xhen they           are unable       tz =-.-.
                                                                                           ..   3 drug-
addicted        pregnant         women in residential                 treatment,       they      resort        to
such options            as battered          women shelters            or nursing       homes.


MATTERS FOR CONSIDERATION


In conclusion,            the increasing              number of drug-exposed                  infants         has
become a serious                health     and social         problem      that     calls      for      an
urgent      national        response.          Expanding         drug treatment             services          might
reduce      the number of drug-exposed                       births      and alleviate           some        of the



                                                        11
family     dysfunction          that      is contributing          to the growing          number of
child     abuse and neglect               cases and foster          placement.


With additional            federal        funding,     the large         gap between the number
of women who could              benefit       from drug treatment                and the number of
residential         and outpatient           slots     available         could     be reduced.


If   the Congress          should       decide    to expand the current                federal
resource       commitment          to treatment        for     drug-addicted         pregnant      women,
several       options      could       be used.       These include:


--       Increasing        the alcohol,          drug abuse and mental               health      services
         (ADMS) block        grant        to the states         in order         to provide      more
         federal      support       for    drug treatment.


--       Increasing        the ADKS Women'~ 3,--                side     from 10 percent          to
         assure     that    expanded treatment                services     under the block             grant
         are targeted        specifically            to substance-abusing             pregnant         women.


mm
         Creating       a new categorical             grant     'to provide        comprehensive
         prenatal       care and drug treatment                 services         to substance-
         abusing      pregnant         women.




                                                     12
--     Increasing       funding      of the Maternal       and Child         Realth     Services
       block   grant       specifically     for     substance-abuse          treatment      for
       pregnant     women.


--     Requiring       states     to include      substance-abuse           treatment      as a
       part    of the package of services              available      to pregnant          women
       under Medicaid.


These options       could       require   more funds     initially,          or funding      could
come from a realignment              of the federal      allocation          for   drug-
supply-reduction           and demand-reduction         activities.           We believe      that
this   commitment of funds could               save money in the long term as well
as improve      the lives        of a future      generation       of children.


Mr. Chairman,       this      concludes    my statement.           I will     be happy to
answer any q-_:z::-         .IS you may have.




                                               13