Running head: EVERY 19 MINUTES 1

Every 19 Minutes: A Legal Analysis of Neonatal Drug Dependency

Haley R. Lamont

Legal Studies Academy

EVERY 19 MINUTES 2

Abstract

This paper takes an in depth analysis of Neonatal Abstinence Syndrome, beginning with an

overview of the issue and the issue of drug dependency itself. This includes the types of drugs

most commonly found to cause NAS and the number of children born each year who are

diagnosed with NAS. Next there is an analysis of Neonatal Abstinence Syndrome that includes

how the syndrome is developed, the effects of different drugs on infants, and the treatment

options for infants. In addition to fetal drug dependency, this paper covers maternal addiction.

Including treatment options for pregnant and drug addicted mothers, legislation against addicted

mothers, and the number of cases reported by doctors versus the number of cases in reality. After

the coverage of maternal addiction, there are 3 legal pieces, including one court case and two

acts. Of the two acts, one has been has been passed by only the House of Representatives, while

the other is an amendment to a previous act made in 2011. There is then a comparison of laws

both state wise and internationally, including places like Tennessee and the United Kingdom.

The paper closes with an interview with Dr. Hendree Jones, a professor and expert on Neonatal

Abstinence Syndrome, in which treatment centers and programs, severity of drugs, opinions on

punishment, and connotation of the word “addiction” is covered. In conclusion, the author does a

final analysis of the causes and effects of Neonatal Abstinence Syndrome and its lack of

treatment options.
EVERY 19 MINUTES 3

Every 19 Minutes: A legal analysis of neonatal drug dependency

Every 19 minutes. Every 19 minutes a drug dependent baby is born. Every 19 minutes a

case of Neonatal Abstinence Syndrome is discovered. To make the matter worse, there are

currently 36 states that don’t have a law requiring doctors to report these cases (Barletta, 2016).

Although this is a very apparent issue, doctors are still very unsure about a lot of the data

surrounding it because of the lack of scientific investigation. In addition to doctors, many people

are unaware of not only the effects of maternal drug use but also what Neonatal Abstinence

Syndrome is in general. This then creates the issue of discovering treatments for both the mother

and child because in a community of people very few know of the syndrome. And with little

knowledge comes very few treatment options which would explain why there are not very many

pregnancy centers in the United States that willingly accept drug addicted mothers, and

therefore, most of the women never seek further treatment (H. Jones, Personal communication,

October 26, 2017). The lack of proper treatment centers for women who are both pregnant and

abuse drugs generates an increases in children born with drug dependency by limiting the

possibility of addiction detection.

The Issue of Drug Dependency

Types of Drugs

Whether it be a prescribed painkiller or a high risk drug like heroin, it is possible to

develop an addiction. The only difference the drugs have on a child are the effects or severity of

the dependency they have. There are also factors of when in the pregnancy the drugs are used

and how frequently the drugs are used. According to Dr. Hendree Jones, who is later referenced

for an interview, the most important things to figure out when a woman comes to a rehab facility

are what drug they are taking, when in their pregnancy they have taken it, and how frequently the
EVERY 19 MINUTES 4

drug is used (H. Jones, Personal communication, October 26, 2017). These three pieces of

information make it possible for doctors to be able to form a treatment plan, with the hopes of

bringing the maternal addiction to an end and prevent severe effects on the infant.

Number of Babies

Over the years, the amount of children born with a drug dependency has increased so

intensively that treatment centers are a necessity now. This is especially prevalent in Penn State’s

Hospital where they alone get at least 20 newborns every year born with a dependency caused by

the mother. The Penn State Hospital says that, “An estimated 1 in 200 babies in the United

States are born dependent on an opioid drug.” Out of those children, a majority of them are cared

for in a NICU until the infant becomes stable. Over 2000 babies were cared for in the NICUs in

Pennsylvania in 2016 due to condition brought on by mother’s substance abuse (Wenner, 2017).

Neonatal Abstinence Syndrome

Development

Through recent studies the cause of Neonatal Abstinence Syndrome has become more

apparent and the illness itself has more of a definition. Doctors have established that the narcotic

or substance the mother is using or abusing travels through the mother’s blood stream and to the

fetus’ placenta ("Neonatal Abstinence Syndrome," n.d.). The most current definition of NAS

(Neonatal Abstinence Syndrome) is “a group of conditions caused when a baby withdraws from

certain drugs he’s exposed to in the womb before birth” ("Neonatal Abstinence Syndrome

(NAS)," 2017). The development of NAS is most commonly from the misuse of prescribed legal

drugs or from the use of illegal drugs such as opioids (Botticelli, 2015).

The Effects of Different Drugs on Infants

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In addition to withdrawal, the baby could have poor intrauterine growth, premature birth,

seizures, and birth defects. Heroin and other opiates can cause withdrawal and seizures that can

last anywhere from 4 to 6 months, while amphetamines are associated with low birthweight and

premature birth. Cocaine use can coordinate with poor fetal growth, developmental delay,

learning disabilities, and lower IQ, and marijuana creates lower birth weights. Alcohol slows

down growth and puts the children at risks for birth defects in comparison to cigarette smoking

which can lead to smaller babies or even a stillbirth. Although every drug effects the infant

differently, they all still have a negative effect on the body and could, if heavily abused, result in

the death of the infant or fetus ("Neonatal Abstinence Syndrome," n.d.).

Treatment for Infants

There is specific treatment plans for NAS dependent on the newborn’s weight and status

("Neonatal Abstinence Syndrome," n.d.). In an informational article published by Boston

Children’s Hospital, the treatment for both minor and severe NAS are presented. In minor cases,

in which the child is simply irritable, the use of swaddling or snuggling children to comfort them

is frequently used. It is also extremely common that because the child’s body is more active from

the drug, the infant needs a higher calorie intake, and therefore will be given a formula with

more calories. The cases of severe dehydration are met with giving the child intravenous fluids.

The more severe cases of NAS, frequently including seizures, are treated with specific drugs. For

NAS related to heroin and opiates, the drug methadone is used, while alcohol dependency is

treated with benzodiazepines. In any treatment involving specific drugs, the treatment drug is

most likely from the same family as the drug the child is dependent on ("Treatments for Neonatal

Abstinence Syndrome (NAS) in Children," 2013).

Maternal Addiction
EVERY 19 MINUTES 6

Treatment Options for Addicted Mothers

Treatment with methadone is and has been the standard of care for pregnant women since

1998. Although after recent studies, there is a possibility that buprenorphine could be a better

option. The use of buprenorphine instead of methadone results in not only a 10 percent lower

chance of NAS but also a shorter neonatal treatment time by an average of 8.4 days. In addition

to that, the infant is more likely to be born with a higher gestational age, weight, and head

circumference. The same study found that women who do divided treatments of methadone and

buprenorphine, instead of pure and constant methadone, are shown to have less of a chance of

having a child born with NAS (Abuse, n.d.). There are many factors that contribute to the

selection of treatment method for the addicted mothers. This factors include but are not limited

to: the substance that has been used, the level of abuse, and the mother’s health and psychiatric

history ("Drug & Alcohol Rehab Centers for Pregnant Women," n.d.).

Laws Against Addicted Mothers

Currently, Tennessee is the only state to have a law specifically addressing drug abuse in

pregnancy being a crime. While in other states like Iowa, health care providers require test and a

report of prenatal drug use. States like Virginia consider neonatal drug use as to be included in

child welfare laws. This means that proper evidence of neonatal drug use can be used in a court

of law to terminate parental rights on the grounds of child abuse or neglect. Although a majority

of states feel it is against the wellbeing of the infant, it is hard to prosecute mothers because of

the lack of inclusion of fetuses in most United States or state laws ("Using Illegal Drugs During

Pregnancy," 2016).

Number of Cases Reported vs. the Reality

EVERY 19 MINUTES 7

Although reporting an incident of maternal addiction may seem like the common thing to

do among health professionals, that is not the case in most states. There are currently 15 states in

the United States that require a health professional to report if there is evidence that the patient is

pregnant and abusing drugs (Miranda, Dixon, & Reyes, 2015). This poses the question as to why

there are not more states who require the report when there are 24 states and the District of

Columbia who consider maternal drug use as child abuse ("Substance Use During Pregnancy,"

2017).

Cases and Acts Regarding NAS and Maternal Child Abuse

Protecting Our Infants Act 2015

Over the span of 12 years (2000-2012) in the United States, the number of infants born

with NAS has increased fivefold. This statistic draws attention from Congress to draft laws to

benefit both the mother and the child. The purpose of the Protecting Our Infants Act of 2015 is to

help identify evidence-based approaches to care for these babies and their mothers. This act

would require the United States Department of Health and Human Services to conduct a study

and develop recommendations for preventing and treating prenatal opioid use disorders and

NAS. This would be done with the assistance of the Centers for Disease Control and Prevention

to improve the availability and quality of data collection related to NAS. All of this with the end

goal of ensuring that all pregnant women have access to proper prenatal care and safety is

provided for mothers and their babies. Proper prenatal care is the primary focus due to the fact

that two thirds of women struggling with drug abuse do not receive the standard of care for

pregnant opioid users, which is medication-assisted treatment with methadone or buprenorphine.

An act similar to the Protecting Our Infants Act of 2015 is the 2011 Prescription Drug Abuse

Action Plan which was never passed by both branches of Congress. Even with the Protecting Our
EVERY 19 MINUTES 8

Infants Act of 2015 in effect, there are only a few states in the U.S. that have prescription drug

monitoring programs. If more states implement drug monitoring programs, the goal is that the

Substance Abuse and Mental Health Services Administration will be able to create a connection

between child welfare and addiction of the mother (Botticelli, 2015).

Infant Plan of Safe Care Improvement Act

The main focus of the Infant Plan of Safe Care Improvement Act is to amend the Child

Abuse Prevention and Treatment Act, requiring certain monitoring and oversight on mothers and

their affected infants. Each infant in the program would have their own personalized treatment to

best ensure their success after leaving medical care. In addition to this, states would be required

to report the number of infants with personalized care each year and whether or not treatment

was initiated in respect to family life and maternal drug use. To enforce the act, the Department

of Health and Human Services would be required to monitor the compliance of states that

receive grants and know the relevant current laws and required state policies and procedures

regarding the care of drug affected babies. The heaviest impact of the Infant Plan of Safe Care

Improvement Act would be to move state health policies towards the federal regulations. As of

May 2016, the act has been passed the House of Representatives and is awaiting a Senate vote

(Barletta, 2016).

Commonwealth of Kentucky v Welch

The case of the Commonwealth of Kentucky v Welch was taken to the Kentucky Supreme

Court in 1993. The matter was regarding Connie Welch due to the fact that she was found

injecting oxycodone into her jugular vein while eight months pregnant in 1989. She was given a

court date instead of going directly to jail because of her condition. When the baby was born in

later in 1989, he had no birth defects and no signs of long term effects, but he was placed in the
EVERY 19 MINUTES 9

NICU because he showed the main symptoms of Neonatal Abstinence Syndrome. Early in 1990,

in Welch’s county, she was charged with abuse, possession of a narcotic, and possession of

paraphernalia. In May of 1990, Welch was found guilty of all three offenses and was sentenced

to a total of 8 years in prison. Later that year in the Court of Appeals, the judges affirmed the

drug charges and vacated the abuse charge. Welch’s attorney made the points that under certain

precedents a fetus is not a person and that the way the court was using the precedent was not how

they were intended to be used. The majority opinion of the court states that the legal issue of

abuse was not found in the case because of the way the precedent defines a human being. To

change this precedent for future cases, the Kentucky Supreme Court rewrote the statute defining

abuse in a manner that addresses fetuses (Commonwealth v. Welch).

Comparison State Wise and Internationally

Tennessee’s Law Against Drug Using Mothers

The number of babies born with NAS in Tennessee had increased fifteenfold in the last

ten years. In 2014 the state government passed a law to “allow women who give birth to babies

‘harmed by’ illegal drug usage to be charged with misdemeanor assault.” Tennessee is the first

state to create a specific law to make it a crime for women who give birth to drug dependent

children. The law has made women afraid to get treatment in light of getting arrested down the

road. In 2015, 30 were arrested in Tennessee with only one serving jail time. This issue is

pressing because taking any kind of painkiller or antidepressant prescribed by a doctor gives the

baby 50% chance of being born with NAS. The problem is that there are not enough detox

treatment options available for pregnant women in the state of Tennessee. Methadone programs

in Tennessee do not accept Tennessee's version of Medicaid, and therefore, there are little to no
EVERY 19 MINUTES 10

treatment options for women in the state, and then the women are stuck in a legal issue as well as

a medical issue ("The Ill Effects of Tennessee's New Drug Law," 2015).

Dr. Jones’ Observations about NAS Internationally

Dr. Hendree Jones, of UNC Chapel Hill, has published an assortment of articles and

studies on NAS and the treatment problem for mothers. In an interview with her she mentioned

that the NAS patients and drug addicted mothers in different countries have so many similarities

and that the legal policies in different places have the biggest effects on the patients. Most

importantly the use of a medical approach works more efficiently. Dr. Jones’ most important

message is that, “The process of engaging people and offering them help them is universal. Even

if some places are more punitive than the United States, the goal is to help, to do whatever we

can” (H. Jones, Personal communication, October 26, 2017).

Study in the United Kingdom by the British Medical Journal

Published in the British Medical Journal, Rishi J Desai et al, worked together on an

observational study entitled “Exposure to prescription opioid analgesics in utero and risk of

neonatal abstinence syndrome.” The study observed pregnant women who were actively taking

at least one prescription opioid drug. They then assessed the time period in which the opioids

were being taken, including both the duration of the drug use as well as the time period in the

pregnancy. The purpose of the study was to try and make a correlation between the type of

opioid use and the diagnosis of Neonatal Abstinence Syndrome. In order to gather people for the

observational study, the Medicaid Analytical extract files were pulled from the years 2000 to

2007. The study showed that drugs such as heroin give the most obvious signs of NAS, while

drugs such as cocaine give the most severe symptoms. The total number of women included in

the study was 290,605 and of those women, nearly half of them had misused at least one harmful
EVERY 19 MINUTES 11

drug during the course of their pregnancy. Of the total amount of women in the study (290,605)

there were 1,705 cases of NAS identified. From this the researchers found the risk factors of each

individual group based on their drug of choice and duration period to find which groups had the

highest risk factor for their child to develop NAS (Desai et al., 2015).

Interview with Dr. Hendree Jones

UNC Horizons

In an interview with Dr. Hendrée Jones, a psychology professor at UNC, a professor of

psychiatry at Johns Hopkins, and the executive director of UNC Horizons, she discussed the

importance of effective treatment on pregnant women who are also addicted to drugs. Dr. Jones

has done research and published over 175 publications on NAS and drug addiction in pregnant

women. Her most current project is UNC Horizons, defined by the University’s Medical School

as, “a substance use disorder treatment program for pregnant and/or parenting women and their

children, including those whose lives have been touched by abuse and violence” ("UNC

Horizons Program," 2017). The mission of UNC Horizons, according to Dr. Jones, is to improve

health and wellbeing the lives of children and women with drug addiction.

Contraceptive Practice Treatment

The interview initially talked about Dr. Jones’ current study and mission to increase the

knowledge and availability of contraceptives as a way to lower the amount of unplanned

pregnancies amongst drug using women and women in general. This mission was sparked by a

study Dr. Jones was reading about in which the statistics said that 86 percent of women who use

drugs have an unplanned pregnancy. Dr. Jones wanted to find out the specifics on the number of

women who have tried drug treatment programs and how that affected their pregnancy. The

answer to that problem was found in a mother study by the New England Journal of Medicine on
EVERY 19 MINUTES 12

methadone treatment comparison. This study states that women who give birth to children that

are drug dependent have tried drug treatment 3 times prior to giving birth. Those same women

reported that the treatment type was not working for them or that the drug treatment center could

not treat them specifically because they were pregnant (H. Jones, Personal communication,

October 26, 2017).

The Severity of Different Drugs

When asked to rank or determine the severity of the most common drugs on children, Dr.

Jones was able to provide the symptoms for each substance. Alcohol is said to be the most severe

simply because the short and long term effects are unknown. It is yet to be known the exact

effects alcohol has on infants because it affects every infant differently and therefore is the most

risky substance to abuse while carrying a child. Second is tobacco because of the long term

effects. The primary effects being negative neurobehavioral outcomes, such as the compromising

of the development of neural passages to the brain, obesity due to being born with a low birth

weight, and the later development of type 2 diabetes (Bruin, Gerstein, & Holloway, 2010). Third

is risk factor drugs like cocaine because of short term effects such as behavior problems and

trouble with early childhood education (Villa, 2017). Finally opioids are ranked last because the

severity depends on the environment.

Opinion on Legislation Against Mothers

When talking about legislation and the punishment of women who give birth to drug

dependent babies, Dr. Jones stated that punishment is ineffective and only leads to less cases

being diagnosed and treated. Dr. Jones feels that it is a bad idea to punish mothers of NAS

affected babies because the government cannot legislate their way out of social issues. The issue

of drug addiction must be treated as a public health issue, and funds need to be there to do
EVERY 19 MINUTES 13

research and to train other health professionals on the topic. At UNC Horizons Program, the

treatment methods that work best are birth methadone for opioid patients and monetary rewards

for women who stay drug free and behavioral therapy. The motto in the program is that patients

have “a pocket full of skills not a pocket full of pills” (H. Jones, Personal communication,

October 26, 2017).

The Connotation of the Word “Addict”

The last topic of discussion, that Dr. Jones was most passionate about, was the

connotation of the word addict when used to describe children with Neonatal Abstinence

Syndrome. This is because according to the definition of an addict, a child is incapable of being

“addicted.” A child, especially an infant, can be only dependent on drugs because they cannot

consent to the use of the addictive substance. Dr. Jones heavily emphasized the negative

connotation that referring to infants as addicts gives, simply because the child was unable to

make the decision that led to their current condition and because it is incorrect to the definition

of an addict.

Conclusion

In an evaluation of the effects neonatal drug dependency has, not only on the infant but

on the mother as well, it is apparent that one of the main causes is the lack of proper treatment

for pregnant women who are addicted to drugs. Not only are there not enough treatment options,

but there are also not enough treatment methods to work for these women without further

endangering their infants. Though there are many different ways a child can be born with

symptoms of defects, there is only one way an infant can become dependent on drugs and that is

through their mother’s use. Education is the number one cause of this problem or in this case

lack of education. Most women have never been educated on the effects drugs have on children,
EVERY 19 MINUTES 14

the effects drugs have on them or the importance of practicing the use contraceptives. Many of

these women who have a child born with Neonatal Abstinence Syndrome are experiencing an

unplanned pregnancy and are already addicted to drugs. In addition to education, the study of

new treatments for Neonatal Abstinence Syndrome needs to be frontiered. There are currently

only two drugs that are FDA approved to treat signs and symptoms of a drug dependency in

infants. This meaning that although methadone and buprenorphine are used to treat women and

infants, that is yet another drug that, with medical assistance, they will have to be slowly taken

off of. But unfortunately, there are very few facilities that will treat women who are both

pregnant and addicted to drugs because of the uncertainty of the child’s outcome and the worry

that these women will use drugs again after the child’s birth. It is for that reason that it is most

apparent that the lack of proper treatment centers for women who are both pregnant and abuse

drugs generates an increases in children born with drug dependency by limiting the possibility of

addiction detection. When women don’t reach out for help or when facilities refuse to treat, it

creates a large amount of neglect for the child’s health and wellbeing and eventually could lead

to legal repercussions. It is for this reason that education, better facilities, and more drug research

are necessary to stop the exponential growth of children each year being born not only with

Neonatal Abstinence Syndrome, but with any form of substance dependency.

EVERY 19 MINUTES 15

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EVERY 19 MINUTES 16

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