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When Rock Bottom Becomes a Fertile Ground

News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences

Dr. Hendree Jones
Hendree Jones, Ph.D.

We all know some patients have more status than others, human nature being what it is,” says psychologist Hendree Jones. “It’s bad enough to have an addiction, but for drug-dependent women, it’s even worse. And pregnant besides? You’re at the bottom.”

What motivates Jones—her work centers on incipient mothers who are substance abusers and on their babies—is that being at rock bottom means there’s little solid research to rely on. “We hear over and over that pregnant women are the most difficult to treat, that their psychiatric illness is more severe,” she says. “Yet not much in journals supports or disproves that. Yes, they have complex problems—addiction doesn’t happen in a vacuum—but they do respond to treatment.” And that makes fertile ground for study.

Jones studies her target group within the framework of the Behavioral Pharmacology Research Unit (BPRU) and the Center for Addiction and Pregnancy. The former, an academic research unit in Psychiatry, focuses on behaviors tied to addictive psychoactive drugs and drug treatment. The latter is a Hopkins Bayview program, both inpatient and residential, that helps pregnant, drug-dependent women awash in problems.  

Part of the ongoing national trial that Jones heads contrasts babies born to mothers treated with either methadone or buprenorphine. And recently, a pilot study suggested one definitive difference. For all its necessity, methadone—the only agent recommended for opioid-dependent pregnant women—can spark withdrawal syndrome in newborns. With buprenorphine, a relative newcomer not yet approved during pregnancy, fewer babies had that problem. Those who did were easier to wean off dependence. “The study’s a first step,” Jones says, “to bring variety into what we offer these women.”

That’s crucial because, for them, the web that environment and biology spin is particularly tangled. Wounds from poverty and domestic violence, quick access to a drug culture, hormonal effects, other psychiatric disease—all play a part. Though the women Jones sees are typically bowed by anxiety and don’t tolerate frustration, they’re unique in other aspects. “So you need more than one approach,” she says.

Because few studies exist, Jones eyes tactics known to help nonpregnant patients, like the motivational interviewing developed for alcohol abuse. “Saying to women, ‘Stop doing drugs. Do you want to harm your baby?’ makes them defensive, even more entrenched,” Jones explains. “But asking, ‘Tell me what’s good and bad about drug use?’ isn’t confrontational. It engages people and it works.” So does contingency management—rewarding patients for staying drug- free. Not everything transfers, however. The field’s standard measures of withdrawal, for example, cite both backache and insomnia—both hallmarks of pregnancy.

Perhaps least understood, Jones says, are biological differences. “If you’re opiate-addicted, you’re hypersensitive to pain. Does pregnancy change that? Are our patients adequately managed during labor and afterward? We don’t know. And if their pain’s intense, something more complex might be at play: 90 percent of our patients have suffered physical sexual trauma. Labor or delivery might re-visit that.” Everything, Jones shrugs, needs a study. 

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Find other Hopkins Newsletter articles from past issues.