315
IMPLICATIONS FOR NEW YORK STATE POLICY* STAN LUNDINE Lieutenant Governor State of New York Albany, New York
O NE OF THE MOST tragic results of the drug epidemic is the devastating effects of substance abuse by pregnant women. Drugs are not only robbing us of our right to a safe society, they are stealing our children and our future. As health care professionals, you know the alarming statistics better than I do. Birth certificates in New York City indicate a more than 2,700% increase in cocaine use by pregnant women between 1980 and 1987. What is worse, we know that self-reported birth certificate data underestimate the magnitude of the problem. Although the terrible impact of drug and alcohol use during pregnancy has been well documented and warnings issued, substance use by pregnant women continues in all levels of society. We are talking about a tragedy of heartbreaking proportions. As estimated 30,000 babies-the population of a small city -are born each year in New York State to mothers who used drugs or abused alcohol during pregnancy. These children suffer withdrawal and a host of serious problems associated with low birth weight and substance abuse. Doctors are often helpless to intervene because drug-abusing mothers are as much as seven times less likely to have prenatal care than mothers who do not abuse drugs. Depending on the substances taken by their mothers, low birth weight babies can be six times more likely to die during their first year of life than those whose mothers did not take drugs. Even normal-weight babies born to drug-abusing mothers have more than a threefold risk of dying. We face a grim situation here -grim, but not hopeless. I was very encouraged by the reports of the various workshops today. Now I would like to bring *Presented as part of a Symposium on Pregnancy and Drug Abuse: Perspectives and Directions held by the Committee on Public Health of the New York Academy of Medicine, the Medical and Health Research Association of New York City, Columbia University School of Public Health, the Maternal and Child Health Program of the New York County Medical Society, the Greater New York March of Dimes, and Agenda for Children Tomorrow March 22, 1990 at the New York Academy of Medicine.
Vol. 67, No. 3, May-June 1991
316
3165. S. LUNDINE
you up to date on what the State of New York is doing to help win the battle against drug abuse. In 1988 Governor Cuomo formed the State Anti-Drug Abuse Council and asked me to serve as chairman. The Council brought together experts, commissioners, and members of the legislature. We looked at the drug problem from all angles. In brief, we found that law enforcement alone is not the answer. We found that a lack of money alone is not the problem. We concluded that the only solution to the drug crisis is a balanced approach that includes community-based efforts-with special emphasis on prevention, treatment, and other ways to reduce demand. One of our key recommendations is based on a strategy of citizen involvement and educating youngsters on the dangers of drug abuse. But we cannot expect students to accept an antidrug message in school if everything they see around them contradicts that message. We must involve families, church leaders, and people in the private sector. We must involve entire communities and encourage them to take effective action to fight drugs. The Council did more than simply come to a conclusion, issue a report, and tell people to get involved. We decided to roll up our sleeves and get involved ourselves. We initiated a program of community demonstration projects in the Bronx, Brooklyn, Queens, and the City of Newburgh. Working closely with the people in these projects gave me an even greater understanding of the terrible impact of drug abuse on mothers and infants. In the area served by the Bronx site, for example, about 46% of mothers abuse drugs during pregnancy. Only one third of these women receive early prenatal care. Many are HIV-infected, and the area has a newborn HIV seropositivity rate three and a half times higher than the rest of the state. Our experiences in community demonstration projects and other areas show that we still have much to learn about combating drug abuse. Existing service structures can be too rigid and inflexible, making it difficult to provide client-centered care. All too often we are hampered by professional biases for or against a particular treatment modality. Service providers sometimes fail to meet the needs of clients. But that we don't know everything should not excuse us for doing nothing. We need an integrated system where detoxification and diagnosis, primary care, drug treatment, social and support services are linked and coordinated. Establishing an integrated system is one top priority. Governor Cuomo and I proposed a number of new initiatives this year in response to requests for more prenatal care, outreach, community involvement, treatment, and services. Our Neighborhood Based Initiative program, for example, is designed to Bull. N.Y. Acad. Med.
NEW YORK STATE POLICY POLICY
NEW
YORK
STATE
317
improve the lives of children and families in high risk communities through early intervention strategies. This community based approach to the delivery of services will unite the efforts of all the state's human services agencies with community leaders and local providers to make our delivery systems more responsive to the needs of families, especially pregnant women. Comprehensive prenatal care will be made readily available, supplemented by an aggressive outreach program. New parents will receive intensive home based prevention services and parenting education. Family planning services will be expanded to high risk teenagers. A program called Family Support Communities has been proposed by Assembly Speaker Mel Miller.* Speaker Miller would like to create eight communities throughout the state for drug-abusing mothers and their children. These residential facilities would offer a variety of treatment and support services, including counseling, medical care, job training, and child care. We are studying the details right now, but I think it is an excellent idea that fits in well with our other antidrug efforts. To help to assure that children have access to adequate health care, the governor and I have proposed the expansion of Medicaid eligibility to children up to age six who live in families with net incomes below 133% of the federal poverty level.* Also proposed is a new child health insurance program to provide access for all children through age 17. ** This plan will assist self-employed and unemployed parents to purchase insurance coverage for their children. The plan will also help employers to provide coverage for their employees' children if such coverage is not currently offered. Clearly we need to improve accessibility, particularly to primary care. It is time to break out of traditional molds, and to look at some new ways to provide services. I would like to see more prevention and outpatient drug abuse services linked with day care programs. An addicted woman with young children now has to choose between treatment and her children unless day care is available. That is one reason we have an enormous increase in our foster care caseload. I would like to see an expansion of in-home services designed to reduce the placement of children in foster care. We need to address special populations who are often multiply-disabled and poly-drug abusers. Family planning, HIV counseling, and care and support for those who are HIV infected are also essential. It is particularly important that we expand our drug treatment system. We know that treatment works. We know that it is cost effective. Treatment helps addicts to rebuild their lives and to become more productive members of *These programs were passed by the legislature in 1990. **A slightly revised version of this proposal was passed by the legislature in 1990.
Vol. 67, No. 3, May-June 1991
318 318
LUNDINE S. LUNDINE S.
society. This year-a year when state revenues are down sharply-the New York State Executive Budget proposes a dramatic expansion of drug treatment capacity. We are calling for 15,000 new residential beds and 20,000 new outpatient slots. Pregnant women and children are a top priority. Project Return in the Bronx is operating treatment services for pregnant women right now. During a visit to Project Return I learned something I did not know before. I had always assumed that pregnant drug abusers were in their first pregnancy. At Project Return I talked with a pregnant woman who said she already had five children and did not want her sixth child to be born addicted as well. Our job is to assure that treatment programs are available to help this woman and others who want to kick their drug habits. Treatment does not always work the first time an addict comes into a program. We expect that some relapse. But studies prove conclusively that overall drug treatment is effective, both as therapy and in terms of cost. Governor Cuomo is the first public official in America with the responsibility to deliver services who has said that our objective should be to provide drug treatment on demand for every person who wants and needs it. The state's fiscal problems make it difficult to reach that objective, at least in the short run. We also have to overcome siting and staffing problems. And I wish that the federal government would put more money into treatment and prevention. But New York is not waiting. We are taking the lead with a balanced program of prevention and treatment on one hand and law enforcement on the other. We want to use our resources in innovative ways, a challenge that health care professionals can help us meet. We know what needs to be done. We know that drug and alcohol abuse cannot be fought in isolation. We know that the criminal justice system cannot go it alone; health care and substance abuse systems cannot go it alone; social services and education systems cannot go it alone; communities, families, and especially pregnant women cannot fight this battle on their own. We must find ways for all of us to work together-we must find new approaches that cut red tape and clear away obstacles to client-centered care. This conference shows that we are on the right track. We are working together to make a real difference in the lives of mothers and children. Your role, of course, is a special one. You shape the strategies that are helping to bring this epidemic under control. You are the experts. We look to you for guidance. We have reached out to you in the past and will again. Your energy, enthusiasm, creativity, and hard work are setting the pace for our state and nation. You are the defenders of a generation yet unborn. Bull. N.Y. Acad. Med.
NEW YORK STATE POLICY
X~~~~~~~E
OLC1
319
Questions and Answers LT. GOVERNOR LUNDINE: I have time for a few questions. I shall even be glad to have your advice. However, my schedule is already made out today, so you don't need to tell me where to go. DR. FINNEGAN: I would not want this audience to go away thinking that for pregnant women in particular outreach itself is a therapeutic modality. As the director of the National Institute on Drug Abuse said, prevention is really good drug abuse treatment, and although outreach workers are important in the overall comprehensive care of these women, and I think that all of us will agree today that comprehensive care is essential, the outreach workers must be put into the context of this overall care. That care must involve medical institutions, good quality care medical institutions that have research attached to the treatment that they are involved in if we are going to do something for these women. MR. LUNDINE: We agree with you absolutely. We are putting outreach workers, for example, health care professionals, into the areas where we are conducting community demonstration projects. We realize that they will identify some of the faults in the system and provide some help. In the Bronx, for instance, we are working with St. Barnabas Hospital to improve their ability to provide for basic care. We are developing a concept called C-DATs, comprehensive drug and alcohol treatment centers. We believe that one of the fundamental weaknesses in the system today, the combined health care and substance abuse system, is the intake of people. It is not enough to have an outreach worker if we do not have a quality system behind him. Finally, let me say just very briefly that you've seen a lot of controversy and some inaccurate reporting, even in one of the most distinguished daily newspapers in America-not to name any one specific paper-about the concept that we had of putting several drug treatment providers and alcohol treatment providers as well as health care providers in one campus-like setting. One of the reasons we want to do that is to overcome siting obstacles. We think it will be easier to get one site that is a little larger than 10 sites where we have 10 neighborhood battles to fight, but another reason is so that we can do research, we can have better intake and better referral and better research and evaluation as to what happens to these people in the end. So we agree completely with the comments that you have made. Vol. 67, No. 3, May-June 1991
IMPLICATIONS FOR NEW YORK STATE POLICY* STAN LUNDINE Lieutenant Governor State of New York Albany, New York
O NE OF THE MOST tragic results of the drug epidemic is the devastating effects of substance abuse by pregnant women. Drugs are not only robbing us of our right to a safe society, they are stealing our children and our future. As health care professionals, you know the alarming statistics better than I do. Birth certificates in New York City indicate a more than 2,700% increase in cocaine use by pregnant women between 1980 and 1987. What is worse, we know that self-reported birth certificate data underestimate the magnitude of the problem. Although the terrible impact of drug and alcohol use during pregnancy has been well documented and warnings issued, substance use by pregnant women continues in all levels of society. We are talking about a tragedy of heartbreaking proportions. As estimated 30,000 babies-the population of a small city -are born each year in New York State to mothers who used drugs or abused alcohol during pregnancy. These children suffer withdrawal and a host of serious problems associated with low birth weight and substance abuse. Doctors are often helpless to intervene because drug-abusing mothers are as much as seven times less likely to have prenatal care than mothers who do not abuse drugs. Depending on the substances taken by their mothers, low birth weight babies can be six times more likely to die during their first year of life than those whose mothers did not take drugs. Even normal-weight babies born to drug-abusing mothers have more than a threefold risk of dying. We face a grim situation here -grim, but not hopeless. I was very encouraged by the reports of the various workshops today. Now I would like to bring *Presented as part of a Symposium on Pregnancy and Drug Abuse: Perspectives and Directions held by the Committee on Public Health of the New York Academy of Medicine, the Medical and Health Research Association of New York City, Columbia University School of Public Health, the Maternal and Child Health Program of the New York County Medical Society, the Greater New York March of Dimes, and Agenda for Children Tomorrow March 22, 1990 at the New York Academy of Medicine.
Vol. 67, No. 3, May-June 1991
316
3165. S. LUNDINE
you up to date on what the State of New York is doing to help win the battle against drug abuse. In 1988 Governor Cuomo formed the State Anti-Drug Abuse Council and asked me to serve as chairman. The Council brought together experts, commissioners, and members of the legislature. We looked at the drug problem from all angles. In brief, we found that law enforcement alone is not the answer. We found that a lack of money alone is not the problem. We concluded that the only solution to the drug crisis is a balanced approach that includes community-based efforts-with special emphasis on prevention, treatment, and other ways to reduce demand. One of our key recommendations is based on a strategy of citizen involvement and educating youngsters on the dangers of drug abuse. But we cannot expect students to accept an antidrug message in school if everything they see around them contradicts that message. We must involve families, church leaders, and people in the private sector. We must involve entire communities and encourage them to take effective action to fight drugs. The Council did more than simply come to a conclusion, issue a report, and tell people to get involved. We decided to roll up our sleeves and get involved ourselves. We initiated a program of community demonstration projects in the Bronx, Brooklyn, Queens, and the City of Newburgh. Working closely with the people in these projects gave me an even greater understanding of the terrible impact of drug abuse on mothers and infants. In the area served by the Bronx site, for example, about 46% of mothers abuse drugs during pregnancy. Only one third of these women receive early prenatal care. Many are HIV-infected, and the area has a newborn HIV seropositivity rate three and a half times higher than the rest of the state. Our experiences in community demonstration projects and other areas show that we still have much to learn about combating drug abuse. Existing service structures can be too rigid and inflexible, making it difficult to provide client-centered care. All too often we are hampered by professional biases for or against a particular treatment modality. Service providers sometimes fail to meet the needs of clients. But that we don't know everything should not excuse us for doing nothing. We need an integrated system where detoxification and diagnosis, primary care, drug treatment, social and support services are linked and coordinated. Establishing an integrated system is one top priority. Governor Cuomo and I proposed a number of new initiatives this year in response to requests for more prenatal care, outreach, community involvement, treatment, and services. Our Neighborhood Based Initiative program, for example, is designed to Bull. N.Y. Acad. Med.
NEW YORK STATE POLICY POLICY
NEW
YORK
STATE
317
improve the lives of children and families in high risk communities through early intervention strategies. This community based approach to the delivery of services will unite the efforts of all the state's human services agencies with community leaders and local providers to make our delivery systems more responsive to the needs of families, especially pregnant women. Comprehensive prenatal care will be made readily available, supplemented by an aggressive outreach program. New parents will receive intensive home based prevention services and parenting education. Family planning services will be expanded to high risk teenagers. A program called Family Support Communities has been proposed by Assembly Speaker Mel Miller.* Speaker Miller would like to create eight communities throughout the state for drug-abusing mothers and their children. These residential facilities would offer a variety of treatment and support services, including counseling, medical care, job training, and child care. We are studying the details right now, but I think it is an excellent idea that fits in well with our other antidrug efforts. To help to assure that children have access to adequate health care, the governor and I have proposed the expansion of Medicaid eligibility to children up to age six who live in families with net incomes below 133% of the federal poverty level.* Also proposed is a new child health insurance program to provide access for all children through age 17. ** This plan will assist self-employed and unemployed parents to purchase insurance coverage for their children. The plan will also help employers to provide coverage for their employees' children if such coverage is not currently offered. Clearly we need to improve accessibility, particularly to primary care. It is time to break out of traditional molds, and to look at some new ways to provide services. I would like to see more prevention and outpatient drug abuse services linked with day care programs. An addicted woman with young children now has to choose between treatment and her children unless day care is available. That is one reason we have an enormous increase in our foster care caseload. I would like to see an expansion of in-home services designed to reduce the placement of children in foster care. We need to address special populations who are often multiply-disabled and poly-drug abusers. Family planning, HIV counseling, and care and support for those who are HIV infected are also essential. It is particularly important that we expand our drug treatment system. We know that treatment works. We know that it is cost effective. Treatment helps addicts to rebuild their lives and to become more productive members of *These programs were passed by the legislature in 1990. **A slightly revised version of this proposal was passed by the legislature in 1990.
Vol. 67, No. 3, May-June 1991
318 318
LUNDINE S. LUNDINE S.
society. This year-a year when state revenues are down sharply-the New York State Executive Budget proposes a dramatic expansion of drug treatment capacity. We are calling for 15,000 new residential beds and 20,000 new outpatient slots. Pregnant women and children are a top priority. Project Return in the Bronx is operating treatment services for pregnant women right now. During a visit to Project Return I learned something I did not know before. I had always assumed that pregnant drug abusers were in their first pregnancy. At Project Return I talked with a pregnant woman who said she already had five children and did not want her sixth child to be born addicted as well. Our job is to assure that treatment programs are available to help this woman and others who want to kick their drug habits. Treatment does not always work the first time an addict comes into a program. We expect that some relapse. But studies prove conclusively that overall drug treatment is effective, both as therapy and in terms of cost. Governor Cuomo is the first public official in America with the responsibility to deliver services who has said that our objective should be to provide drug treatment on demand for every person who wants and needs it. The state's fiscal problems make it difficult to reach that objective, at least in the short run. We also have to overcome siting and staffing problems. And I wish that the federal government would put more money into treatment and prevention. But New York is not waiting. We are taking the lead with a balanced program of prevention and treatment on one hand and law enforcement on the other. We want to use our resources in innovative ways, a challenge that health care professionals can help us meet. We know what needs to be done. We know that drug and alcohol abuse cannot be fought in isolation. We know that the criminal justice system cannot go it alone; health care and substance abuse systems cannot go it alone; social services and education systems cannot go it alone; communities, families, and especially pregnant women cannot fight this battle on their own. We must find ways for all of us to work together-we must find new approaches that cut red tape and clear away obstacles to client-centered care. This conference shows that we are on the right track. We are working together to make a real difference in the lives of mothers and children. Your role, of course, is a special one. You shape the strategies that are helping to bring this epidemic under control. You are the experts. We look to you for guidance. We have reached out to you in the past and will again. Your energy, enthusiasm, creativity, and hard work are setting the pace for our state and nation. You are the defenders of a generation yet unborn. Bull. N.Y. Acad. Med.
NEW YORK STATE POLICY
X~~~~~~~E
OLC1
319
Questions and Answers LT. GOVERNOR LUNDINE: I have time for a few questions. I shall even be glad to have your advice. However, my schedule is already made out today, so you don't need to tell me where to go. DR. FINNEGAN: I would not want this audience to go away thinking that for pregnant women in particular outreach itself is a therapeutic modality. As the director of the National Institute on Drug Abuse said, prevention is really good drug abuse treatment, and although outreach workers are important in the overall comprehensive care of these women, and I think that all of us will agree today that comprehensive care is essential, the outreach workers must be put into the context of this overall care. That care must involve medical institutions, good quality care medical institutions that have research attached to the treatment that they are involved in if we are going to do something for these women. MR. LUNDINE: We agree with you absolutely. We are putting outreach workers, for example, health care professionals, into the areas where we are conducting community demonstration projects. We realize that they will identify some of the faults in the system and provide some help. In the Bronx, for instance, we are working with St. Barnabas Hospital to improve their ability to provide for basic care. We are developing a concept called C-DATs, comprehensive drug and alcohol treatment centers. We believe that one of the fundamental weaknesses in the system today, the combined health care and substance abuse system, is the intake of people. It is not enough to have an outreach worker if we do not have a quality system behind him. Finally, let me say just very briefly that you've seen a lot of controversy and some inaccurate reporting, even in one of the most distinguished daily newspapers in America-not to name any one specific paper-about the concept that we had of putting several drug treatment providers and alcohol treatment providers as well as health care providers in one campus-like setting. One of the reasons we want to do that is to overcome siting obstacles. We think it will be easier to get one site that is a little larger than 10 sites where we have 10 neighborhood battles to fight, but another reason is so that we can do research, we can have better intake and better referral and better research and evaluation as to what happens to these people in the end. So we agree completely with the comments that you have made. Vol. 67, No. 3, May-June 1991
