Critical Support Where High-Risk Pregnancy Meets Addiction

Photograph courtesy of MAHEC

By all accounts, it looked like twenty-eight-year-old Amelia Carmelo had turned her life around by the end of 2018. After more than a decade of heroin and opioid addiction, she had been free from illicit drugs for more than four years and was in a stable relationship. For the past year she’d driven thirty minutes each week to see her addiction counselor.

Carmelo began her nascent recovery in early 2015 after spending several months in jail. She managed to string together a few weeks of recovery by sheer force of will but knew from experience that she could only white-knuckle it for so long before she relapsed.

She found a doctor in Polk County, North Carolina, who prescribed Suboxone, a combination of buprenorphine and naloxone used to curb the opioid craving. But after a few months the doctor’s practice was shut down by authorities for violating prescribing guidelines. Unable to find another local physician authorized to prescribe the drug, Carmelo felt she had to make a choice: relapse or find another way to score Suboxone. She resorted to paying hundreds of dollars a week to illicit dealers or anyone willing to sell it to her.

Then in spring 2019, she missed her period and noticed other body changes that indicated she might be pregnant. Overcome by both shock and denial, she needed two positive over-the-counter pregnancy tests before she would accept the results. That’s when she had what she calls a “freak-out.”

“I was really crazy. I was taking the meds and my life was still crumbling, but I was scared to tell my counselor what I’d been doing,” Carmelo says. “My fiancé put his foot down and said, ‘If you don’t talk to her about it, I will.’ I did, and the counselor said, ‘Go to MAHEC, Amelia. They will take care of you.’ I was like, ‘What is MAHEC?’”

Wedged between the Blue Ridge and Great Smoky Mountains in Asheville, North Carolina, MAHEC (the Mountain Area Health Education Center) is an academic health center established in 1974 to improve the training and retention of health care professionals in North Carolina’s sixteen western and mostly rural counties. MAHEC is funded via state appropriations in partnership with the University of North Carolina (UNC) to establish and expand branch campuses of the UNC School of Medicine, Gillings School of Global Public Health, Eshelman School of Pharmacy, and Adams School of Dentistry. The state-of-the-art Asheville campus also provides primary care, obstetrics-gynecology (OB-GYN) services, dental care, sports medicine, behavioral health care, pharmacotherapy, and nutrition services. Notwithstanding MAHEC’s big footprint, when it comes to health care, Western North Carolina continues to be a place with too many problems and too few solutions.

The population is older, sicker, and poorer than the rest of the state. There is a shortage of primary care doctors. Seven of the region’s sixteen counties have no practicing OB-GYNs, and six hospital labor and delivery units have closed in less than five years. It is not unusual to drive more than forty miles on two-lane roads through mountain passes for basic care. This region is also ground zero for the state’s opioid epidemic—a person here is more likely to die from an opioid overdose than from a car accident.¹

Those dismal facts led MAHEC to create Project CARA (Care that Advocates for Respect, Resilience and Recovery for All), a perinatal substance use treatment program focused on saving the region’s most vulnerable mothers and babies. Established in 2014 by MAHEC’s high-risk obstetrics unit to reduce barriers to treatment and quality obstetrical care, Project CARA is both a clinic and a network of resources. It is also the only obstetrics safety-net provider for the western region of the state. It sees about 200 patients each year, who are, on average, White, twenty-six years old, and in a second or third pregnancy.

An Obvious Need

Even in addiction circles, no group is more stigmatized than pregnant women with substance use disorder. It’s not uncommon to view drug use during pregnancy as child abuse, which is often treated as a crime that is subject to prosecution and jail time by law enforcement. So whenever an expectant woman calls or walks into the clinic to confess her struggles with substance use disorder, Melinda Ramage, Project CARA’s medical director and cofounder, is going to embrace them.

Ramage knows that a routine OB-GYN visit may be the first time a woman is willing to confess her illicit drug use. In fact, the vast majority of pregnant women first disclose their substance use disorder to their OB-GYN provider.² She believes that admitting one’s addiction is the first step in breaking the cycle of trauma and addiction. “Our job is to ensure that our patients feel safe enough to tell us what’s going on and then help them access the resources they need to have a healthy pregnancy and birth,” she says.

Affectionately called Mel by patients and colleagues alike, Ramage is a ball of energy who doesn’t so much enter a room as sweep into it. Despite doing this work for eight years, she speaks about it with such enthusiasm you might think it’s all new to her.

Ramage began her career as a psychiatric nurse in the Navy. In 2002 she and her family moved to Asheville, where she joined MAHEC’s high-risk obstetrics unit part time while earning her nurse practitioner degree from Western Carolina University. After graduating in 2009, she got her first in-depth experience with addiction medicine while working in a residential treatment facility. She returned to MAHEC in 2012 in the Maternal-Fetal Medicine (MFM) department, consulting on high-risk conditions in pregnancy. The need for something like Project CARA was obvious.

“By this time, our MFM team was seeing a steady stream of referrals from all over the western region to evaluate opioid use in pregnancy,” Ramage says. “I was extremely fortunate that the head of our division was 100 percent supportive of developing this work.”

‘Help Them Move Forward’

Initially, it had taken Carmelo some time to work up the nerve to contact Project CARA. “I called them one day in tears because I was scared,” she recalls. “I’d been taking this medicine off the street for almost three years at that time. So I was like, ‘What if this has already hurt my baby?’ They had me come in and welcomed me with open arms and understanding.”

Carmelo’s first appointment lasted nearly two hours. The medical team reviewed her medical and substance use history, talked about her personal goals, and discussed treatment options and available resources. But when the physical exam began, she fell apart. She hadn’t let anyone know that she was still dealing with the trauma of incarceration, intermittent homelessness, and a rape that resulted in a child she gave up for adoption.

“I hadn’t been completely honest because I didn’t feel like I needed to be. But when I realized they weren’t there to judge me or hurt me, I told them, and they understood where I was coming from,” she says.

The Centers for Disease Control and Prevention statistics on abuse and violence are sobering. They report that one in four women have experienced domestic violence and one in five have been raped at some point in their lives.³ Medical services can themselves be traumatizing because they often involve asking sensitive questions and intimate physical exams. That’s why Project CARA says it begins with the assumption that every patient has a history of trauma and needs trauma-informed care to overcome the wounds underlying addiction.

“Trauma-informed care means making sure we treat them with respect and try to normalize these forms of addiction as disorders,” says physician Susan McDowell, Project CARA’s hepatitis C program lead. “Addiction is a chronic disease, just like diabetes or hypertension. It’s a part of who they are, not who they are.”

Ramage is quick to point out that substance use disorder is a brain disease, not a lack of willpower. Pregnant women with a history of addiction are at greater risk for relapse.² If and when that happens to someone in her care, Ramage views it as part of a chronic medical condition, not a failure on the individual’s part. “I compare it to someone with diabetes who splurges on sugary foods or someone with high blood pressure not taking prescribed medication,” she says. “You would never say those people had failed; instead, you help them move forward.”

More than 80 percent of Project CARA’s patients receive medication-assisted treatment (for example, with Suboxone), which is a corrective but not curative intervention that helps improve adherence to prenatal care and addiction treatment programs. Suboxone can be prescribed in the primary care setting, but methadone, another option, is only offered only at a methadone clinic or an opioid treatment program. These medications, approved by the Food and Drug Administration, have been shown to reduce the risk for pregnancy complications that accompany continued drug use or sudden opioid withdrawal, such as fetal distress, preterm births, and underweight babies.⁴

Medication-assisted treatment is not without risk, however. It can cause babies to be born with a risk for neonatal abstinence syndrome,⁵ a group of conditions that can occur when newborns withdraw from substances they were exposed to in utero. Symptoms may include tremors, irritability, sleep problems, seizures, poor feeding and sucking, and vomiting, all of which are treatable and have not been found to have any significant effect on cognitive development.

Suboxone works by tightly binding to the opioid receptors in the brain to blunt cravings and allow people who suffer from addiction to reclaim their lives. Unfortunately, many people—including many who use it—believe that it is a crutch that must ultimately be discarded to achieve real recovery.

“One of the first questions I get when we start folks on medication-assisted therapy is, ‘How long will I be on it?’” McDowell says. “If you have diabetes and you’re on insulin or metformin, no one would ask when you’re going to stop taking that.”

Nicole Ross, program director for Behavioral Health Group, an opioid addiction treatment center in Asheville whose caseload often includes Project CARA patients, has developed a back-of-the-envelope calculation: “We tell people that we want you to give the medication the same amount of time that you gave your using habit. So if you put your body through drug abuse for however long, give it that long to heal.”

‘Getting People Connected’

Project CARA is funded primarily through billing for medical and behavioral services, grants, and state appropriations. A large part of its success is the full-spectrum, wraparound care model that connects patients with the services they need. Finding one’s way through a complex web of available services is a challenge for anyone but can be particularly daunting for patients struggling with an addiction and all of the issues that come with it.

Tammy Cody is a licensed social worker with twenty-five years of experience focusing on the mother-baby dyad. As Project CARA’s lead care coordinator, she oversees complex care for patients involved with multiple agencies and systems such as detention and homelessness and helps patients create individualized action plans that often include mental health care, addiction treatment, social services, and housing. Cody is often the first contact for many women who come to Project CARA. Although roughly half of patients come in on their own, like Carmelo did, many are required to come by a law enforcement or Social Services agency official.

“If someone shows up pregnant in the jail and they’re using substances, [authorities] will call me for a referral into Project CARA for obstetrical care and substance abuse treatment and whatever else she might need,” Cody says. “Our collaboration strengthens obstetrical and gynecological care and helps us make a plan for safe care for moms and babies.”

The Julian F. Keith Alcohol and Drug Abuse Treatment Center in Black Mountain, North Carolina, is an adult residential and detox/crisis stabilization treatment facility. It’s also one of only three psychiatric state hospitals and one of a few options for uninsured people. If a Project CARA patient needs detox or is struggling with a relapse, they are referred to this state-run, eighty-bed facility, where they spend five to seven days in detox and two to three weeks in inpatient treatment.

“Being able to connect all of those services has been really cool and innovative,” says the center’s director, Erin Bowman. “We’re not under the same umbrella, but we’ve come together as a group to figure out how to serve these women better. The relationships we have help make sure they get everything that they need, which can be really hard in North Carolina.”

Behavioral Health Group, likewise, is located just up the road from the MAHEC campus. It provides daily dosages of methadone and Suboxone for about 275 patients who don’t require inpatient care but are deemed too high-risk for a Suboxone prescription to be used independently. At any given time, that may include up to six Project CARA patients.

“If I could replicate [MAHEC’s] model for perinatal and parenting women, I might be out of a job,” says Ross of Behavioral Health Group. “The systems are there, and there’s help for people. It’s just getting people connected to where they need to go and giving them a warm handoff to make sure they actually go in the door.”

Ross was involved in the early planning that led to Project CARA. Her knowledge about what care template would be most effective and enduring for patients was born out of experience. She had been where most of these women are: battling a years-long opioid addiction.

“Parenting is hard. Being a mom is hard. Being a mom when your life is a mess is really hard. Having a safe place to say that changed the course of my life,” Ross says. “I was a Project CARA mom before there was a Project CARA. I tell people, ‘My daughter saved my life.’ I went in pregnant, struggling with things, and was met with compassion and empathy. That’s why I choose to live my recovery out loud. If I hadn’t been able to see someone else recover, I wouldn’t have believed that people do get better, moms do recover, and not everybody’s recovery looks the same.”

The Hub-And-Spoke Model

Given the scale and scope of North Carolina’s opioid problem, too few providers are able to prescribe opioid replacement medication. Medication-assisted treatment is regulated more strictly than opioid analgesics: Doctors must complete an eight-hour training and apply for a federal waiver to prescribe it. Most of North Carolina’s waivered physicians practice in cities, making the shortage particularly acute in the sparsely populated western region. Ramage says that 50 percent of the patients treated at the Project CARA clinic in Asheville come from outside Buncombe County because they cannot find medication-assisted treatment closer to home.

Almost since Project CARA’s inception, Ramage and her team have pondered how to build the capacity and infrastructure to best serve patients where they live. The hub-and-spoke model of health care emerged as the best option.

With this highly scalable, efficient design, the main campus (hub) receives the heaviest resource investments and supplies the most intensive medical services; it is complemented by satellite campuses (spokes) that provide more limited services. Making it work requires a team that is willing and able to educate and share knowledge with each other to ensure that patients get high-quality care at every location.

So far, Project CARA has expanded to include Polk and McDowell Counties, where staff provide training and care management support to providers in community health centers and local health department clinics. “It’s an informal agreement,” Ramage says. “We don’t have memorandums of understanding, but we have teams that say, ‘We’re gonna do evidence-based practice and connect to those resources.’”

A combined $1 million grant from the Foundation for Opioid Response Efforts and the Dogwood Health Trust, which works to improve health outcomes in Western North Carolina, will help expand access to treatment and medication to other counties.

If and when these satellite programs get off the ground, they may look a little different from the original, but Project CARA will continue to provide technical and provider support. “This is a model that, in its basic construct, is evidence-based and has the same goals but can be adapted to what best serves the community where it’s being done,” according to Ramage.

‘Sustain Their Recovery’

Just five minutes away from the MAHEC campus is Mission Hospital, the flagship of nonprofit Mission Health’s five hospitals, the only Level II trauma center in the area, and a Project CARA collaborative partner. Nowhere is the toll of the opioid crisis more evident than here, where each year roughly 400 babies are born with exposure to illicit drugs in utero, according to Susan Mims, the hospital’s vice president for children’s services.

For patients at Mission Hospital who have a relationship with Project CARA, Cody coordinates everything from length of hospital stays for moms and babies to urine drug screens to maternal-fetal medicine referral and counseling. When women arrive at Mission Hospital for delivery, the labor and delivery team has already received their prenatal records and a heads-up from Project CARA.

Mission Hospital has developed a standardized treatment protocol to ensure that every mom, regardless of her history, receives the same care. “We want to make sure that our own biases don’t play into the care,” says Mary Cascio, director of nursing for labor and delivery at Mission Hospital. “We know that they’re scared, so we ask ourselves how we best care for them and provide them with all the information and support they need to take a baby home that’s going to have more needs than a normal newborn.”

Social Services gets involved to determine which resources and referrals the new moms need to have the best chance for a positive outcome. These might include home health care, developmental follow-up, and possibly foster care placement for the child.

For many Project CARA moms, however, that is not the case. Data from 2017 show that compared with the preprogram days, patients were 35.8 percent less likely to test positive at delivery for illicit drugs.⁶ As a result, many are able to leave the hospital with their babies. “And if social service agencies remain involved, it can help them sustain their recovery and keep their families intact,” Cascio says.

Success is different for every Project CARA mom. For some moms it means leaving the hospital with their baby. For other moms it’s placing the child in the care of extended family so they can build a stronger foundation in recovery. Whatever their goals, the moms are responsible for developing the relationships and strategies to get there, Cody says.

Nine months after Carmelo gave birth to a healthy, beautiful baby, she remains in sustained recovery and tethered to Project CARA. She makes the thirty-minute drive from her home in Hendersonville to attend group therapy meetings. There, she shares openly about her recovery and the almost-daily challenges in sobriety she still faces as a mom and partner. “It helps to talk about it with other people who are going through the same things and know all about it,” she says. “But no matter what, it’s still hard. It’s very hard.”

NOTES

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