New moms in Alabama face suspicion over error-prone drug screens

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Christen Townsend didn’t know it yet, but she was in danger of losing custody of the baby that hospital staff were prepping her to deliver.

Around 15 minutes before she was scheduled to be wheeled back to the OR for the c-section birth of her daughter, a nurse walked into her hospital room and said she needed to speak with Townsend privately.

Townsend’s family, including her husband, mother, two sisters and her 1-year-old daughter, left the room.

The nurse looked at her. “Did you know you would fail a drug screen?” Townsend recalled her asking.

Townsend wasn’t sure what she meant. She had given the staff a list of her prescribed medications and said there was no way she could have anything else in her system.

The nurse told her she’d tested positive for Subutex, she said. Townsend had never heard of it. It’s a drug, similar to Suboxone, used to treat opioid addiction.

“The nurse said they’d have to get a social worker and CPS (Child Protective Services) involved to make sure I could even take my child home,” said Townsend, 22, who lives in Limestone County with her husband and their two young daughters. “They told me they would prepare for my child being drug addicted. It was insane.”

The United States has seen a dramatic increase in opioid use disorder among pregnant women in the past decade, according to the U.S. Centers for Disease Control. About 32,000 newborns are diagnosed each year with neonatal abstinence syndrome, a form of withdrawal due to exposure to drugs in utero. But while hospitals use drug screens to identify and treat mothers and babies with addiction disorders, those same screens can trigger loss of custody and even arrest for mothers, rather than treatment.

In Alabama, drug-screening policies and procedures differ from hospital to hospital. At Madison Hospital, where Townsend was delivering, all mothers are tested when they’re admitted for delivery. False positives aren’t that uncommon on those initial drug screens, medical professionals told AL.com, a statement reinforced by multiple published medical studies.

Townsend continued to deny she’d taken Subutex as hospital staff took her back to the OR for the delivery. She watched as her doctor wrote on the big white board in the delivery room that she was addicted to Subutex, she said.

“I kept telling them there’s no way possible this is in my system,” she said. “They kept telling me, if you’re using Subutex you can tell us, this is a safe environment, and because if you are, we need to take precautions for you and your child. But no matter how many times I told them I’d never heard of Subutex in my life, they kept pushing me to tell them.”

Her daughter was delivered without incident. But it would be another 48 hours filled with anxiety and fear at the possible loss of custody of her newborn daughter and her 1-year-old before Townsend said she finally got answers.

Two days after delivery, she finally convinced a nurse to find out what was going on. No doctors had come to talk with her about the drug test. She said the nurse came back a few hours later and said a second drug test came back negative. A urine test on her daughter was also negative, she said.

She said the nurse apologized and told her that false positives on the drug screen happen “all the time.”

“It scares you to death,” said Townsend. “You think, ‘I’ve waited this long to see and hold my child, and because of one thing that’s not even true, I’m not going to see her again.’”

Leading the nation

Alabama considers drug use during pregnancy a crime.

The state’s chemical endangerment law – originally intended to help law enforcement jail parents for exposing their kids to home-based drug labs – has been used to prosecute women who expose their unborn babies to drugs in utero.

In fact, Alabama leads the nation in charging women with felonies for drug use during pregnancy, a 2015 investigation by AL.com and ProPublica found.

While Alabama doesn’t require hospitals to drug test pregnant women, healthcare providers have to refer substance-exposed infants to child protective services in order for the state to receive federal funding.

A positive drug screen – false or otherwise – can become an Alabama mother’s first step toward loss of custody of her children and potential incarceration.

Last week, a Huntsville-area mother named Rebecca Hernandez made national headlines after her doctor said she was separated from her newborn shortly after giving birth at Crestwood, a private hospital in south Huntsville. Her doctor, Yashica Robinson, told media outlets that Hernandez had eaten poppy seeds, which triggered a false positive on a drug screen.

“This is a well-known relationship, between poppy seed bread and tripping a urine toxicology screen for drugs of abuse,” said Dr. Morissa Ladinsky, a Birmingham pediatrician who has worked with mothers and newborns. “This issue is well-known and it happens a lot.”

Dozens of legal drugs are also well documented for triggering false-positive drug screens, from antihistamines to attention deficit disorder medication, acid reflux pills to blood pressure pills and even ibuprofen. For example, the cough suppressant medication dextromethorphan, found in over-the-counter medicines like Robitussin, caused false positive drug screens about 24% of the time, according to one study cited in a 2017 Mayo Clinic report.

Ashley Moseley of Huntsville said she got a false positive drug screen in April 2017 when she went to the hospital for the birth of her daughter. Her urine test was positive for methamphetamine, she said, that her doctor later suspected was because she’d taken over-the-counter heartburn medication.

“It was embarrassing, and I thought the whole floor of nurses thought I was a bad person,” said Moseley, who said she learned of the positive test after asking a nurse why they were doing a urine test on her newborn daughter. “When I went to the recovery floor, it felt like taking the walk of shame.”

The test on her daughter later came back negative, but not before her doctor told her that the Alabama Department of Human Resources had been called. She credits her doctor for interceding on her behalf until the newborn drug screen came back.

“I’ve been warning friends that if you take anything, write it down at the hospital,” she said. “We don’t think of a heartburn antacid as medication.”

Alabama moms are at the mercy of their hospital’s drug screening policy, one which may not take into account false positives before triggering a call to DHR or law enforcement.

Crestwood Hospital tests all mothers for drugs, according to policy documents provided to AL.com. In Hernandez’s case, the positive drug screen appears to have triggered a call to DHR. Hernandez told WAFF 48 News that her baby and her older child were placed with her aunt and uncle under a temporary custody order. DHR spokesperson Barry Spear told AL.com that DHR did not separate Hernandez from her baby.

Proper protocol for a positive urine drug screen is a second confirmatory test, according to the U.S. Substance Abuse and Mental Health Services Administration.

But those tests can take two to three days to complete. Some mothers may be discharged from the hospital by then, potentially separating them from their newborns while they await the test results.

Hospital by hospital

Alabama doesn’t require hospitals to drug test women who come to give birth. That means whether you get drug tested depends entirely on the policy at the hospital where you’re delivering.

Some Alabama hospitals, such as Huntsville Hospital and Madison Hospital, run drug screens on every pregnant woman admitted. Others, such as UAB Hospital, only drug test pregnant women if certain criteria are met, such as a prior known history of dependence, prior involvement with DHR or if the mother appears to be in an altered state.

Madison Hospital president Mary Lynne Wright told AL.com the hospital works to keep mother and baby together unless the baby needs special medical care.

“While our drug testing policy is designed to help us keep new mothers and babies safe, we understand it can cause anxiety for mothers whose initial screening comes back positive,” Wright said in a statement. “When that happens we send the urine sample for further confirmation testing.”

Dr. Stephanie Israel, the neonatal hospitalist at Huntsville Hospital, works with opioid-exposed newborns. She said false positives do happen, but Huntsville and Madison Hospitals always perform confirmatory lab tests after a positive drug screen.

While the confirmation test is being run, she said, a social worker employed by the hospital gets involved, looking into the mother’s history and doing an in-person assessment. The idea is not to get DHR involved unless a positive drug test is confirmed. If it is, the state’s mandatory reporting law requires medical professionals to contact CPS if illegal drugs are suspected.

“I am against criminalizing mothers,” Israel said. “I want mothers to seek prenatal health, I want mothers to come to the hospital and I want to be able to help, to get them into a rehab program. New motherhood is a great time to help these moms, a golden moment when you catch the mom who wants to do better to help her child.”

Informed consent

Ladinsky, the Birmingham pediatrician, believes universal testing is the best way to address substance abuse, along with hospital policies geared toward keeping mothers and babies together. Testing all mothers can also guard against racial or other profiling, she said.

“This is good medicine,” she said. “If we as pediatricians or neonatologists know that an infant was exposed to an opioid in utero, the way we care for the baby in the hospital is different. We can anticipate and increase our awareness for withdrawal, which is managed medically and clinically and environmentally. And we can increase our levels of blanketed support for (mother and baby) as they begin a new life together – recovery, support, mental health.

“We see this as a chronic illness, not a criminal justice issue or a weakness of the will.”

But it’s not clear whether most hospitals that do drug test mothers get explicit consent. The AL.com/ProPublica investigation found that few hospitals in Alabama ask permission from mothers before drug testing that can lead to a loss of custody and even criminal charges.

Some hospitals may consider the consent-to-treat form that patients sign on admission to the hospital as sufficient to cover drug screenings, said Kirsten Clark with Alabama Cohosh Collaborative, an advocacy group dedicated to reducing disparities in reproductive healthcare.

But that doesn’t give a mother the information she needs to truly consent to a screen, Clark said.

“There’s definitely not (the level of) informed consent happening where moms know a positive could fall under chemical endangerment laws and your baby could be taken and you could be charged,” said Clark. She said she has heard from some moms that their hospital told them CPS would be called if they refuse a drug screen.

“If there’s no informed refusal,” she said, “there’s no informed consent.”

Before coming to Alabama, Ladinsky worked in Ohio, at the heart of the opioid epidemic. At the hospital where she worked, she said, if a woman refused a drug test, doctors would instead do a urine drug screen on the baby.

“We know universal testing can improve the health and welfare of baby and mom, but it needs to be done in a structured way, with everyone on board in agreement of what we do and how we do it,” Ladinsky said. “That’s what I’d love to see cleared around this.”

A new approach

There are states working to address drug use in pregnancy with treatment rather than arrest.

In West Virginia, widely considered the epicenter of the opioid epidemic, a state-funded Drug Free Moms and Babies program provides drug screening and treatment services at maternity clinics around the state. A 2012 pilot program was so successful that it grew to now 15 sites around the state.

Pregnant women and new mothers are referred to drug treatment programs and receive long term follow-up for two years after the baby’s birth, including a recovery coach, home visits and other services.

A report on the first four years of the program found it reduced the percentage of women who screened positive for drugs from 81% in the first trimester to 22% at delivery.

‘Like a light switch’

Townsend said the moment she learned that her drug screen showed positive for Subutex, “it was like a light switch flipped” with the medical staff. She said her nurse became cold and distant, refusing to answer questions and not visiting her room often.

“They treated me differently,” she said. “You would think people would care more about how you’re feeling. Because of a mistake that one nurse made, the whole staff that day thought I was a drug addict. And even worse, they thought I would do drugs while I was pregnant.”

Townsend said another nurse was much kinder than the first, but she believes a doctor – any doctor – should have come to her room to talk with her about the positive drug test.

Clark said putting new mothers in a situation where they fear loss of custody or are treated as drug addicts can exacerbate an already overwhelming and stressful time for women.

“Even if all that happens is a false positive, this is obviously harmful to mom’s mental health and to mother-baby bonding,” said Clark. “There are a lot of levels to this. Even if mom and baby are not physically separated, it’s still traumatic experience.”

Now, five months after the birth of her daughter, Townsend said she’s working to put the experience behind her. She never asked for an apology from the hospital, she said, but has told friends who are pregnant about her experience. She wants to see hospitals treat mothers more sensitively, particularly after an initial positive drug screen.

“I don’t want other people to have to go through that,” she said. “The last thing you should think about when you go into a hospital and deliver your baby is whether your baby will be taken from you.”

Updated 2/9/2020 at 1:10 p.m. to add quote from Madison Hospital President Mary Lynne Wright.