“Another druggie from the jail is in triage,” a labor and delivery nurse muttered as she entered the workroom. In the middle of sign-out, the OB senior resident lamented, “These patients are such a disaster. We can never find a place for them to go.”
I was a new family medicine attending at a large academic teaching hospital orienting on labor and delivery. Since I was still establishing my role in a hospital where no other family physicians were delivering babies, I refrained for the time being from commenting on the nurse’s stigmatizing language use in describing the patient. Instead, I volunteered to help the OB team by seeing the patient.
Ms T. was lying handcuffed to a stretcher, dressed in iridescent orange scrubs. Two armed jail guards sat by her side. Drenched in sweat and with shaking hands, she said in a pained and desperate voice: “They haven’t given me anything. I’ve been in solitary for 3 days! I’m worried that something’s going to happen to my baby.”
I glanced at the fetal heart tracing on the monitor and quickly reassured Ms T. that her baby did not seem to be in distress. Responding to the standard labor and delivery triage questions, she shared with me that this was her third pregnancy and that she thought she was in her late first trimester.
After obtaining a history and physical, I returned to the clinician workroom. The OB attending told me that, although the local jails generally allowed nonpregnant inmates to withdraw at the jail, they brought in pregnant inmates who were withdrawing from opioids, due to a concern that withdrawal would cause miscarriage. With limited treatment options available within the academic health system, the OB team inevitably struggled to find a methadone clinic to take the patient, since few were willing to take inmates. I asked if buprenorphine, the medication predominantly used in office-based settings to treat opioid use disorder, was a possibility and was told that the only buprenorphine clinics in town did not take insurance and were cash only.
Having trained in a residency program that routinely administered buprenorphine in the care of pregnant women with opioid use disorder, I saw a need that I could readily address as a family physician. I learned that buprenorphine was available on the hospital formulary but used primarily for opioid withdrawal management. I went back to Ms T. and explained to her the different options. After she agreed to try buprenorphine, I worked with the nurses to start her and then arranged to see her in clinic the next week.
Two jail guards accompanied Ms T. to her weekly visits. Initially, she was reserved and answered most of my open-ended questions with one-word answers. Her behavior made me feel inadequate. As a family physician, I valued relationships with my patients, and I judged myself for the inability to connect with her.
A few weeks later, I was surprised when she voluntarily asked me a question: “Can I keep seeing you after I get out of jail?”
I replied in the affirmative. With prompting, she shared that she had a court date this week and was likely going to be released on probation.
The next week, I barely recognized Ms T. when she arrived in clinic. No longer in orange scrubs, she had her hair done up and was wearing makeup. As I talked with her over the next few weeks, I realized the transformation was not only external but also internal. She shared with me that her pregnancy had motivated her to live a drug-free life; jail had been a wake-up call. She talked about her hope that she would be able to regain custody of her two other children, who were now with her mother, and her desire to return to community college.
As my connection with Ms T. blossomed, I felt like I was also growing into my role as a family physician working in an obstetrics program that previously did not have family physicians. Initially, I had felt scorned in a specialist-focused system. My attempts to develop an obstetric addiction program faced many administrative hurdles in a large academic center. Many health system leaders questioned why a family physician was trying to start a program that they viewed as outside of family medicine’s scope. Some of the obstetricians openly questioned the need for substance use treatment and believed that developing such a program would attract undesirable patients while scaring away others.
My growing relationship with Ms T. strengthened my resolve to keep fighting against these barriers and helped me realize that, as a family physician, I did have a unique role to play in caring for pregnant women with substance use disorder. Trained to provide holistic care to people of all ages using the biopsychosocial model, family physicians can provide both comprehensive care for both the mother and the child and longitudinal care beyond the confines of the prenatal and 6-week postpartum period. Family physicians who provide both maternity and addiction care not only can apply their expertise in the biopsychosocial model to meet the needs of pregnant women with substance use disorder, but also have an opportunity to develop fulfilling relationships with patients during a transformational time period.1
Ms T. delivered a baby girl at full term and continued to follow me for her care after delivery. With her input, I started a postpartum substance use group where women met weekly, often bringing their babies and sometimes older children. As a family physician, I have felt privileged to be able to accompany Ms T. As she transformed in my mind from the patient in orange jail scrubs to someone whose story, goals, and aspirations I knew intimately, she helped me realize the unique skill set I brought as a family physician to care for pregnant women with substance use disorder and gave me the confidence to fight for the care that she needed.
