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. Author manuscript; available in PMC: 2021 Feb 16.
Published in final edited form as: Community Ment Health J. 2019 Oct 19;56(3):426–434. doi: 10.1007/s10597-019-00478-6

Examining Stressors and Available Parenting Resources for Opioid-Using Mothers: Qualitative Findings from an Inpatient Substance Use Treatment Program

A Moreland 1, C Hartley 1, S DelMas 1, A McRae-Clark 1
PMCID: PMC7885178  NIHMSID: NIHMS1668910  PMID: 31630288

Abstract

Given the alarming opioid epidemic, high prevalence of parents involved in substance use treatment programs for opioid use disorder, and critical role that parenting stress plays on opioid use and relapse, the current study examines stressors experienced by mothers enrolled in substance use treatment. Specifically, interviews were conducted with mothers with opioid use disorder (OUD) enrolled in an inpatient substance use treatment program, to identify common themes and develop recommendations related to interventions targeting common stressors among this population. A significant number of parent-related, substance use-related, and other stressors were present prior to and during substance use treatment; with more stressors reported during treatment than prior to treatment. Mothers with OUD reported that they would be interested in receiving parenting services, but that relevant parenting resources were not offered during substance use treatment.

Keywords: Opioid use disorder, Stress, Parenting, Qualitative

Introduction

Opioid misuse is a national epidemic. An estimated 11.8 million Americans (4.4% of the population) misused opioids and 2.1 million met criteria for opioid use disorder (OUD) in the past year (Hughes et al. 2016; Rudd et al. 2016; SAMHSA 2002). Consequences of OUD are catastrophic, and include development of more chronic and severe substance use disorders, overdose, and unintentional fatality (Bohnert et al. 2011; Rudd et al. 2016; Webster 2017). Researchers, clinicians, and policy makers have called for increased attention to combat this rising epidemic, and specific strategies have called for the prevention and treatment of opioid misuse and addiction (National Institutes of Health 2018).

Stress is a significant risk factor for OUD, based on long-standing theories that both acute and chronic stress play a critical role in the motivation for drug use (Sinha 2001). Specifically, the stress-coping model of addiction postulates that opioid use simultaneously reduces negative affect while increasing positive affect, thus serving to reinforce drug use as a coping strategy (Wills and Shiffman 1985). As the mental health consequences of opioid use are more profound for women than men, stress may elicit a particularly negative effect on women (Simpson and McNulty 2008). This is especially true for women exposed to behavioral stress, as myriad studies have identified a link between behavioral stress and drug use (Miczek et al. 1999; Piazza and Le Moal 1996). Taken together, these models suggest that individual’s may use opioids to enhance mood and alleviate emotional distress, which may be particularly true when faced with heightened behavioral stress.

Despite evidence that behavioral stress is significantly linked to increased opioid use, less literature has examine the role of stress caused by parenting—which is surprising given the large number of substance users what report being parents; 59–70% of adults in substance abuse programs are parents (SAMHSA 2002). This is particularly troublesome due to evidence that the cumulative impact of minor inter-personal stressors are more critical than single major stressful events (Fox et al. 2010). Further, the cumulative effect of seemingly minor daily stressors, such as those related to parenting (i.e., challenging child behaviors, time consuming childrearing responsibilities), may cause more stress than major life events (Almeida 2005). Therefore, parents may experience significantly higher rates of daily behavioral stress than non-parenting counterparts.

In addition to parenting stress related to child responsibilities and life events, parents with OUD may experience added stress due to the increased risk of Newborn Opioid Withdrawal Syndrome (NOWS), a consequence of perinatal opioid use. NOWS has increased fourfold to sevenfold since 1999 (Haight et al. 2018; Patrick et al. 2012). NAS often involves extended hospitalization, pharmacotherapy, extensive neonatal monitoring, and higher hospital charges (Jones and Fielder 2015; Patrick et al. 2012), and can increase the risk for infant death, infant cardiac arrest, and loss of child custody (Velez and Jansson 2008). Importantly, infants with NAS display unique behavioral concerns such as negative temperament, decreased facial expressions, high-pitched crying, limited sensory processing and regulation, state control deficits, motor and tone control difficulties, and dysregulation of autonomic signs of stress (Lester et al. 2004; O’Brien and Jeffery 2002), which interfere with feeding, sleeping, growth, emotion regulation, and social interaction (Velez and Jansson 2008). These infant behaviors can be challenging and lead to increased stress, especially for mothers with OUD who often lack emotion regulation and thus, the ability to effectively respond to the infant (Trull et al. 2000). This stress can increase the risk for relapse, aggressive behavior, and/or neglect of the baby (Velez and Jansson 2008). Further, mothers with OUD often have comorbid mood disorders and adverse childhood experiences, which can further impact the stress of mothers with OUD.

Overview of the Study

The current study examines sources of reported stress among mothers with OUD, as well as the available resources offered for this population in a southeastern city (of note, the rates of OUD in the south are double that of the northeast) (Bateman et al. 2014; Desai et al. 2014). Specifically, qualitative, semi-structured interviews were conducted with mothers with OUD enrolled in an inpatient substance use treatment program. The purpose of the interviews was to identify common themes and develop recommendations related to interventions targeting common stressors among this population.

Methods

Participants

Individual, semi-structured in-person interviews were conducted with a sample of mothers with OUD engaged in inpatient substance use treatment; all women were enrolled in the Opioid Treatment Program (OTP), indicating that their primary diagnosis was OUD. The sample (n = 17) consisted of 100% mothers, mean age 31.50 (SD = 7.95; range 23–49). Participants reported their races as Caucasian (90%) and African American (10%). Participants had a range of 1 to 5 children. Children ranged in age from 1 to 16 years old (mean child age = 4.96, SD = 4.99). Eleven percent of the participants reported current involvement with child protective services and 43% of the 17 women did not have any children living at home with them. Fifty percent reported that they used multiple substances, with 29% also reporting alcohol use, 7% reporting marijuana use, and 7% reporting cocaine use.

Procedures

Participants were recruited from a substance use treatment center in a mid-size city in the sourtheast United States, which provides a range of substance use treatment services. The treatment center includes inpatient, intensive outpatient, and outpatient treatment services. Participants in the current study were all enrolled in inpatient treatment, where approximately 27 individuals are admitted in any given time; average length of stay is 90 days. Prior to recruitment, project staff attended a staff meeting at the treatment center, where the study and procedures were presented and described. Project staff were then invited to present and describe the study to women enrolled in the inpatient substance use treatment program. Enrollment was open to all mothers enrolled in the inpatient program; 100% of mothers in the inpatient program at time of study chose to enroll in the study. Interested participants completed informed consent and were able to ask questions regarding the study prior to enrollment. All procedures were approved by the Medical University of South Carolina IRB.

Measures

To assess participant’s reported stress, as well as the available resources offered for this population, a semi-structured qualitative interview was created. This interview consisted of questions divided into three parts: (1) demographics (6 questions) and substance use treatment history (6 questions); (2) daily hassles and parenting stress (10 questions); and (3) available resources to support parenting (3 questions), interest in parenting resources (8 questions), and barriers to accessing parenting resources (5 questions). Follow-up probes were used to clarify information provided whenever necessary.

Data Analysis

Data analysis consisted of a qualitative content analysis (Boyatzis 1998) informed by grounded theory (Glaser and Strauss 1967), which is utilized to explore participants’ unique perspectives via the identification of themes/patterns that naturally emerge from the data and the systematic classification of these themes (Elo and Kyngäs 2008). Specifically, a three-step inductive approach was utilized, in which each participant’s interview responses (i.e., raw data) were carefully examined to develop a comprehensive codebook to capture all possible themes emerging from the data. The codebook was then used by two independent coders re-review all of the interviews, to code and analyze each participant’s responses to the interview questions (Boyatzis 1998; DeCuir-Gunby et al. 2011). Coders were able to apply more than one code to participant responses if applicable. The interrater reliability for the double coded interviews was 91% and ranged from 87 to 96%. Inter-rater discrepancies were discussed and resolved by the two independent coders. Finally, themes were refined, merged, and/or subdivided into sub-themes via collaborative discussion in multiple in-person meetings until a comprehensive codebook was developed. NVivo 12 software was used for data management and analysis. Interviews lasted between 18.75 and 41.40 min (M = 26.75, SD = .30) and were audio-recorded and transcribed. Demographics and substance use treatment history were extracted from the transcribed interviews and computed using IBM Statistical Package for the Social Sciences (SPSS) software, version 23.

Results

Results are presented within each of the two main areas, including (1) daily hassles and parenting stress, and (2) available resources to support parenting, interest in parenting resources, and barriers to accessing parenting resources.

Daily Hassles and Parenting Stress

Three overarching themes, each with their own sub-themes, emerged from the participant’s answers to the interview questions. Each is described below with representative quotes provided throughout for illustrated purposes (P = participant, followed by interview number).

Parent-Related Stressors Prior to Entering Substance Use Treatment

Seventeen participants (100%) discussed parent-related stressors prior to entering inpatient substance use treatment. Specifically, fifteen participants (88%) discussed stressors about the parenting role, which included child behavior problems (n = 8; 41%), school concerns (n = 2; 12%), child welfare involvement (n = 1; 6%), being separated from children or not being able to see or talk to children (n = 4; 24%), shared parenting responsibilities/co-parenting issues (n = 6; 35%), child activities and/or appointments (6%), general day-to-day stressors or daily hassles (n = 3; 18%), being a single parent or having no help (n = 3; 18%), and child mental health problems (n = 2; 12%). Some examples of parent-specific stressors reported by women prior to entering inpatient substance use treatment included:

  • [My child] tends to complain a lot. She wants the attention, which I give her… Sometimes she does little things for more attention. (P06)

  • I think there’s a point where we have butted heads on parenting rules and trying to understand that she didn’t know who to listen to. It was causing a lot of turmoil for her emotionally. (P06)

  • Just staying involved in general. Sometimes it’s just overwhelming. (P09)

  • [My child’s] father doesn’t live around here, so that causes a lot of stress. (P09)

Fifteen participants (88%) mentioned substance use-specific stressors, including children not understanding substance use, treatment, or recovery (n = 3; 18%); being under the influence impacts functioning or inability to be emotionally present (n = 11; 65%); lack of adult support or understanding of substance use (n = 2; 12%); risk for relapse (n = 3; 18%); and legal problems, arrest, or law enforcement involvement (n = 3; 18%). As some women described substance use-specific stressors prior to entering treatment:

  • It was stressful to me being fatigued. Heroin, to me, was more of energy. It gave me energy. (P12)

  • My moods are sporadic. It’s just a sporadic up and down type of mood from day to day. (P03)

  • It was hard because I couldn’t tell my daughter [that I was in substance use treatment]. I told her that I was going to an unemployment class. (P03)

  • When I was there, I wasn’t really there. (P03)

Fourteen participants (82%) remarked on other stressors prior to entry into treatment, which included transportation problems (n = 4; 24%), employment/job (n = 3; 18%), financial concerns (n = 11; 65%), house-related concerns (n = 3; 18%), childcare (n = 2; 12%), family problems or discord (n = 8; 47%), domestic violence/abuse (n = 4; 24%), mental health concerns (n = 2; 12%), and physical health problems (n = 1; 6%).

Parent-Related Stressors During Substance Use Treatment

Seventeen participants (100%) discussed parent-related stressors during substance use treatment. Specifically, seventeen participants (100%) reported parent-specific stressors, including child behavior problems (n = 2; 12%), child welfare involvement or being court ordered/mandated for treatment (n = 4; 24%), being separated from children/family and/or cannot see or talk to children (n = 14; 82%), no parenting resources offered (n = 1; 6%), inability to control the environment outside of treatment (n = 7; 41%), child activities and/or appointments (n = 1; 6%), child physical health problems (n = 3; 18%), high risk behaviors (e.g., substance use, delinquency, risky sexual behavior) in children (n = 1; 6%), general day-to-day stressors or daily hassles (n = 6; 35%), being a single parent or having no help (n = 2; 12%), or being overwhelmed (n = 1; 6%). Some examples of parent-specific stressors reported during substance use treatment:

  • I went to the DSS [child welfare] office yesterday and actually spoke with a supervisor because I haven’t been contacted in 2 months. I was fed up. I’ve been calling and leaving messages, and they go and visit my kids. Now this caseworker they’ve had for 2 months is about to not be there anymore…I have to be supervised when I see them. Which is ridiculous. (P01)

  • I don’t get to see my kid. I get home [from class] sometimes at 10:00 and she already be in bed. I’m sad about that because you know I be wanting to know how her day went, and what’s going on and stuff like that. I’m not able to talk to her so that’s like a little downer. (P03)

  • It’s the fear of not being able to be with [my child] that’s most stressful. (P04)

  • My son is just constantly misbehaving. I don’t know how to talk to him. I don’t know how to express to him like what the consequences are. I lose my mind and I will lose myself, I will lose my child. That’s scary to me. (P06)

Fifteen participants (88%) reported substance use-specific stressors, including children not understanding treatment (n = 5; 29%); comorbid mental health concerns (n = 3; 18%); withdrawal symptoms or craving substances (n = 4; 24%); being a recovering addict, lack of knowledge of non-drinking activities, or anxiety due to anticipated lack of structure after leaving treatment (n = 6; 35%); risk for relapse (n = 6; 35%), time commitment required for substance use treatment (n = 8; 47%), lack of adult support or understanding of substance use (n = 2; 12%); legal problems, arrest, or law enforcement involvement (n = 1; 6%); substance use treatment-related rules or structure (n = 4; 24%); children living in the treatment center with them (n = 4; 24%); or transition into the world outside of treatment center (n = 1; 6%). As some mothers described substance use-specific stressors:

  • I don’t know about other parents, but if you are dealing with substance abuse and mental health, sometimes you get to working on the recovery part and not the mental health issue. (P02)

  • I try to keep busy, to keep your mind occupied off of drugs. (P03)

  • It’s hard when you try to talk to other people about [my substance use problem] and they don’t really understand what’s going on. (P02)

  • I guess being here [is stressful], with the money that it costs to go here, then missing work to be here, and everything on top of that. Then, they’re getting things that end up going on in the evenings. (P05)

  • I guess when you go to treatment, and you feel better, and then you go home, and it’s crazy. You’re gone for 6 h. It’s hard because I never know when I’m going to get home really. It would be hard to have a job. I wouldn’t know if I would make it in. (P10)

Fifteen participants (88%) discussed other stressors that they experienced during substance use treatment, including transportation problems (n = 2; 12%), employment/job (n = 6; 35%), financial concerns (n = 6; 35%), house-related concerns (n = 4; 24%), childcare (n = 4; 24%), family problems or discord (n = 6; 35%), and relationships with other people in treatment (n = 9; 53%). Some examples of other stressors included:

  • So you have stress directly around [my child], but the also family stress. (P01)

  • Well, right now, I’m still struggling with a transportation situation. I’m not working. I’m unemployed. The money is still an issue. Just not having certain resources to rely on. That’s hard. (P02)

  • It’s expensive paying for Drug Court each week. I have to pay $50.00 restitution to this place I owe, plus $30 to $50 a week so it’s like $350 I have to pay a month for this plus bills. We are both stressed out because of financial stuff. (P04)

Positive Impacts of Being a Parent

Eight (47%) participants mentioned positive impacts of being a parent. Specifically, six participants (n = 6; 35%) remarked that their children were motivation for seeking help. As some mothers described that their children were motivated for seeking help:

  • He’s the reason I want to stay clean. For me, it’s just like he’s my motivation and I can focus on my recovery around him. That’s the whole reason I came here was because I want to learn to be a single parent away from drugs and do it with him involved. There’s no better way to learn how to do it, than do it from the start. (P12)

  • I mean, honestly, I’m doing this for my son. (P04)

Five participants (29%) mentioned that they would like to be good mothers. One example included, “I just want to keep going ahead and doing what I have to do and being a good parent this time.” (P03)

Available Resources, Interest in, and Barriers to Accessing Parenting Resources

Sixteen participants (94%) discussed parenting services currently offered in treatment. Specifically, nine participants (53%) remarked that no parenting resources had been offered to them during their encounters with substance use treatment programs. Four participants (24%) mentioned that parenting services have been offered as part of their substance use treatment, but that the services were not relevant. Some examples from mothers included:

  • This lady comes and sits in my house for an hour to watch me play with my daughter. If she comes, she normally has a big bag of stuff. We’ll do arts and crafts or try and get her to match the colors. (P01)

  • …they may offer you a sheet of here’s some like resources in the area if you’d like. (P06)

Five participants (29%) discussed that the group leader informally discussed parenting as part of other group services, but that it was not a formal or planned discussion topic within substance use treatment. As some mothers described:

  • Yeah, my group leader talked about it because some people got DSS [child welfare] involved. (P03)

  • Not necessarily parenting topics. I mean, we have talked about our kids, but nothing specifically like a video or course. (P09)

Five participants (29%) reported that they had received case management services indirectly related to parenting during their substance use treatment such as childcare, transportation to medical appointments, or general case management. Some case management examples described by mothers included:

  • They have a case manage that sets them up with transportation. (P11)

  • The daycare here helps a whole lot. (P13)

Suggested Program Logistics and/or Structure

Seventeen participants (100%) made suggestions regarding program logistics and structure. Specifically, sixteen participants (94%) made suggestions whether they would prefer to learn about parenting resources during group or individual treatment, as 71% (n = 12) suggested group treatment, 12% (n = 2) suggested individual treatment, and 35% (n = 6) suggested a combination of group and individual treatment. Some examples of suggestions regarding group versus individual treatment include:

  • I think, for me, it helps a lot more to hear other moms who have been there, that have older kids, and they can tell you how it worked or didn’t work with them. The group setting works better for me. (P13)

  • [Being in a group], that’s the key part of it, everybody hearing everybody else’s stories. (P05)

Three participants (18%) discussed whether they felt the parenting resources should be held during or outside of substance use treatment. One hundred percent suggested holding the program during current treatment. As some mothers described:

  • I feel that if it was all in one place, it’d be easier but I also feel that I don’t want to be here all day. (P01)

  • Incorporated inside, because a lot of people are already giving their time, their 4 hours. I don’t think it would work after group. (P02)

Seventeen participants (100%) mentioned a specific group of parents that should be targeted when offering parenting resources. While thirteen mothers (77%) said that all parents would benefit from receiving parenting resources, other participants discussed specific groups of parents including single parents (n = 6; 35%), child welfare-involved parents (n = 8; 47%), parents of younger children (n = 6; 35%), parents of older children (n = 1; 6%), parents with mental health concerns (n = 1; 6%) families who have experienced domestic violence (n = 1; 6%), parents who have relapsed (n = 3; 18%), younger parents (n = 3; 18%), women (n = 1; 6%), or men (n = 3; 18%). As some parents described:

  • Especially for single parents. They need all the help they can get. (P11)

  • I would definitely say those of younger children, for one, definitely, because that’s a highly stressful time, especially if you’re trying to go through recovery. (P09)

Finally, four participants (27%) remarked on whether the program should be voluntary or mandatory, with 50% (n = 2) feeling that the program should be voluntary/optional and 75% (n = 3) that the program should be mandatory.

Topics, Considerations, and Suggestions for Parenting Services

Seventeen participants (100%) discussed additional topics, considerations about parenting services. Specifically, seventeen participants (100%) made suggestions regarding content that they would like to see a part of parenting services, including behavior management and/or discipline (n = 11; 65%); clear commands, rule setting, effective communication, and/or ignoring (n = 14; 82%); parent–child communication skills and/or parent–child interactions (n = 4; 24%); child coping skills and/or emotional regulation (n = 2; 12%); general routine or structure (n = 6; 35%); sleep routine or curfew (n = 17; 100%); school-related concerns (n = 15; 88%); planning activities with children (n = 1; 6%); play/learning time (n = 3; 18%); praise (n = 4; 24%); home safety (n = 4; 24%); child health/medical concerns (n = 3; 18%); and nutrition (n = 4; 24%). Some examples regarding program content include:

  • How to communicate with your child so that they understand what you’re trying to get across. (P13)

  • Behavior management types of things would be helpful. (P01)

Twelve participants (71%) remarked on special considerations that should be incorporated for substance users, including offering a joint parent/child education class (n = 4; 24%), providing education about substance use to children (n = 4; 24%), taking into account that parents are sober for the first time (n = 3; 18%), taking into account the fear of being reported to child protective services (n = 4; 24%), the importance of building trust (n = 4; 24%), offering content on transitioning back into the home (n = 1; 6%), not judging the parents (n = 3; 18%), group leader should be a recovering addict (n = 1; 6%), taking into account that many substance users are child trauma victims (n = 1; 6%), and considering that parents are in the process of transitioning back into the home routine (n = 2; 12%).

Barriers to Engagement in Parenting Resources

Fourteen participants (82%) commented on barriers to engagement in parenting resources. Specifically, one participant (6%) reported that the group leader should be a parent in order to effectively deliver services. Twelve participants (71%) remarked on barriers related to group members, including that parents may be too overwhelmed/stressed to engage in parenting resources (n = 1; 6%), shame and/or embarrassment (n = 7; 41%), being unwilling to ask for help or already confident in parenting ability (n = 8; 47%), partner or family members are not supportive (n = 1; 6%), and fear of being reported to child protective services (n = 3; 18%). As some mothers described barriers related to group members:

  • [Parents] are probably nervous about talking about parenting and their kids. (P13)

  • Some [parents] could be ashamed. A lot could have to do with shame, because maybe they made some choices that put their children in certain situations. They don’t want to discuss, divulge it between strangers. (P02)

Seven participants (41%) mentioned logistical barriers, which included travel to and from the group/transportation (n = 5; 29%), lack of childcare (n = 2; 12%), work schedule (n = 4; 24%), and parent doctor appointments (n = 1; 6%). Some examples included:

  • Work schedule, kid’s doctor appointments. I mean a lot of these people in here don’t have cars, or walk, and the Medicaid bus takes forever. (P01)

Other Resources Entirely

Three participants (18%) suggested other resources that they would like to have included in substance use treatment, including offering individual treatment related to parenting (n = 1; 6%), offering employment or financial assistance (n = 1; 6%), assistance with childcare (n = 1; 6%), and offering parent resource line outside of services (n = 1; 6%).

Discussion

This study examined sources of reported stress, as well as available resources offered to parents with OUD in inpatient substance use treatment programs. Mothers with OUD reported a significant number, as well as a broad range of stressors prior to and during inpatient substance use treatment. Interestingly, reported stressors fell into the same themes of “parent-related stressors, “substance use-related stressors,” and “other stressors” regardless of whether they were experienced prior to or during treatment. Further, mothers reported the same stressors being present during and following treatment as prior to treatment, with additional stressors identified during treatment. This suggests that, while substance use treatment addresses many factors including substance use, medication management, coping skills, and risk for relapse, it may not target many of the stressors reported by mothers involved in inpatient treatment. This is particularly troublesome given that 59–70% of women in substance use treatment programs are mothers (SAMHSA 2002), and that stress is a common trigger for opioid relapse, even for women who undergo pharmacological management (Sinha 2001; Nair et al. 2003; Kumpfer and Fowler 2007). With general rates of relapse to opioids after detoxification at > 90%, most mothers with OUD will relapse at some point in pregnancy, causing fetal distress due to intoxication and withdrawal (Fischer et al. 2006; Lander et al. 2015; SC DHHS 2016).

Results from these qualitative interviews suggested that, although the program involved in the current study was a substance use treatment program directly targeted for parents, and parenting resources were often offered—mothers did not view them as relevant to them. These results are novel and add to current literature because it goes beyond current research stating which parenting resources are currently available in substance use treatment programs, and adds information on how relevant parents see this information. In addition, a gap in the literature is being addressed by adding information on the types of parenting resources that mothers with OUD see as beneficial and would like to see incorporated into substance use treatment. Findings suggest that further investigation into the content of parenting resources in treatment programs is necessary, as 100% of mothers reported interest in receiving parenting resources. Further, mothers had many suggestions regarding content for parenting resources, as well as approach and logistics in offering such services. Overall, mothers suggested that parenting services targeting mothers with OUD should be mandatory, offered in the context of current treatment, and offered in a group setting. Importantly, 73% of mothers discussed that special considerations should be incorporated into parenting resources offered to mothers with OUD, which is consistent with literature highlighting the significant needs identified in mothers with OUD (LaGasse et al. 2003; Women’s Service Strategy Work Group 2005; Madigan et al. 2006; Coalescing on Women and Substance Use 2007).

Clinical Implications and Considerations

Current available resources for parents with OUD include evidence-based treatments (EBTs) for opioid use, relapse prevention, and coping mechanisms (Williams et al. 2012; Ehde et al. 2014). Based on comprehensive reviews (Ashley et al. 2003), as well as research specific to mothers with OUD (Jones et al. 2014), the most effective treatment would include comprehensive care to include prenatal and postnatal care, specialized drug addiction treatment, and education and facilitation of positive mother-infant interactions with the infant (Briggs et al. 2008; Velez and Jansson 2008; Jones et al. 2014). Currently, separate evidence-based treatments (EBTs) exist to address each of these needs, but they are often not integrated within substance use treatment programs, and thus, most mothers with OUD do not receive these comprehensive services (Minozzi et al. 2008; Jones et al. 2014; SC Department of Health and Human Services 2016).

Based upon feedback from mothers with OUD completing a substance use treatment program with additional resources focused on parents, 53% of them reported that no parenting resources were offered within treatment; with an additional 24% reporting that, although resources were offered, they were not relevant. However, 100% of mothers reported interest in incorporating parenting resources and/or education into their substance use treatment. Mothers made a number of recommendations regarding program content, approach, structure, and logistics that should be considered when planning effective services to address the stressors associated with OUD among mothers in substance use treatment. Results of the interviews were with external literature suggesting that addressing stressors among mothers with OUD would directly impact risk for relapse (Russell and Mehrabian 1997; Leventhal and Cleary 1980; Marlatt and Gordon 1985; Wills and Shiffman 1985; Koob and Le Moal 1987; Sinha 2001). Thus, incorporating interventions into substance use treatment to decrease stress among mothers with OUD is critical to recovery from substance use, and interventions exist to address this specific population. For example, the mindfulness-based parenting (MBP) intervention has been effective at reducing general and parenting stress among women who are in treatment for substance use disorder and who have infants or young children (Short et al. 2017).

While medication assisted treatment (MAT) is the standard of care for OUD in pregnancy (SC DHHS 2016), mothers with OUD have a range of additional needs including relapse prevention, treatment for chronic pain, increased coping mechanisms, and parenting resources and education. Research indicates that the most effective treatment would address these concerns simultaneously (Velez and Jansson 2008; NIDA 2017; Jones et al. 2014). While evidence-based treatments exist for substance using mothers to improve parenting skills and education (Jansson et al. 2003; Sword et al. 2009), results from these qualitative interviews are consistent with the overall literature stating that they are often not integrated within treatment for mothers with OUD (Jones et al. 2014; SC DHHS 2016); and thus, most mothers with OUD do not receive these services. Overall, findings suggest that developing a comprehensive treatment to target the various treatment recommendations of mothers with OUD, including relapse prevention, treatment for chronic pain, increased coping mechanisms, and parenting resources and education, would be extremely beneficial and well-received by mothers with OUD involved in substance use treatment programs.

Limitations and Future Directions

Several study limitations are important to note. First, semi-structured interviews were conducted with a sample of mothers with OUD enrolled in an inpatient substance use program, thus limiting our abilities to generalize conclusions beyond this population. Future research should examine stressors and available resources in other treatment programs across the United States, and should also examine both inpatient and outpatient programs to examine similarities and differences. Results would also be strengthened by collecting a larger quantitative survey of mothers involved in substance use treatment. Second, the qualitative study does not examine differences in stressors based upon other factors, including use of multiple substances, multiple children, and whether children are living in the home or not. Future research should investigate whether there are different stressors based upon these factors. Third, these results reflect the views of mothers involved in substance use treatment programs and not the views of providers. Future studies will need to assess the providers views, specifically related to parenting resources offered within treatment programs, via the use of focus groups, semi-structured interviews, and larger quantitative surveys. Finally, although the double-coding technique (Boyatzis 1998) was used to ensure reliability to the qualitative content analysis, qualitative coding could include the coder’s unique perceptions and biases, which may have influenced specific themes extracted from the raw data.

Conclusions

Qualitative results indicated that mothers with OUD reported a significant number of parent-related, substance use-related, and other stressors that were present prior to, during, and following substance use treatment; with more stressors reported during and following treatment than prior to treatment. Further, mothers with OUD reported that relevant parenting resources were not offered during treatment, although they stated that they would be interested in these services. Results of this study suggest that incorporating resources and education to address stressors specifically reported by mothers with OUD into inpatient substance use treatment programs would be beneficial and well-received. Thus, findings from the present study have significant clinical implications to prevention of negative outcomes for both mothers with OUD involved in substance use treatment, and also their children.

Acknowledgements

This study was supported by Grant 5K12DA031794-03 to support the first author, as well as by NIH Grants P50DA016511, R01DA021690, and K24DA038240 to support work by the last author.

Footnotes

Conflict of interest There are no conflicts of interest to report and authors certify all responsibility for the manuscript.

Ethical Approval University IRB approval was obtained and adhered to. Informed consent was obtained for all human subjects research; the research did not involve animals.

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