The nation is watching Tennessee for new legislation that would allow women to be criminally charged if they use drugs during pregnancy that harm their newborns.
State and national groups have asked Gov. Bill Haslam to veto the bill before Tuesday, saying criminalization isn't the right approach to stem the state's growing numbers of babies born dependent on drugs.
This complicated epidemic raises many questions, yielding few simple answers. Here are a few:
What's the scope of Tennessee's problem?
Health officials report drug-dependent births — known as neonatal abstinence syndrome, or NAS — grew tenfold between 1999 and 2010. But mandatory counting only began in 2013, so numbers were expected to increase. There were 855 drug-dependent births in 2013 and 253 so far this year, putting the state ahead of last year's pace. Babies with neonatal abstinence syndrome can cost more than $60,000 to care for in the hospital, compared to less than $8,000 for a healthy birth.
A huge share of drug-dependent births are related to expectant mothers' use of pain medications, or opioids, which are often legally prescribed by doctors. Heroin is also an opioid.
Another complication: Drug addiction treatment relies on drugs that can cause neonatal abstinence syndrome. That could make it difficult for prosecutors to untangle which drugs harmed a newborn.
So what's best for babies and expecting mothers struggling with opioid addiction?
Doctors agree the "gold standard" for treating opioid addiction is through careful administration of addiction therapy drugs — either methadone or buprenorphine.
Abrupt detoxification is actually dangerous to a pregnancy and can cause miscarriage or pre-term labor, said Jessica Young, an obstetrician who runs the Vanderbilt University drug dependency clinic for pregnant women.
"You're avoiding the withdrawal, you're keeping people from having cravings, so they don't have those impulses, those drives to use," she said. "It's obviously a very complicated process that requires a lot of psychological work, a lot of emotional work."
Although doctors agree on the best approach, carrying it out isn't easy. Methadone itself is addictive. Access to the drugs is extremely limited and expensive and they're not always covered by insurance. After birth, mothers can require six months or more of ongoing care.
"Relapses happen," Young said.
If doctors agree on treatment, what's the controversy?
The legislation. That's the simple answer. State officials and lawmakers are offering competing approaches.
Doctors, children's hospitals and health officials want women to get treatment. That could require everything from increased funding for drug programs to insurance companies changing what they pay for. Last year, lawmakers passed the Safe Harbor Act to give pregnant women priority access to treatment programs and to protect their custody rights as they try to get clean.
The competing approach — criminalization — is backed by law enforcement, including prosecutors who want to be able to charge women with assault for harm done to their infants. In some counties, prosecutors say the only way to get women into treatment is to first charge them and then put them into drug court.
The controversy is partly in how the approaches overlap. Drug-addicted mothers have been encouraged to come forward for help, but could now face criminal charges for doing so.
Wait. Isn't drug use already a crime?
Yes, but what's different is that the new law doesn't charge women for possessing, manufacturing or selling drugs. It would give prosecutors the power to charge women if they believe they can prove that prior drug use — during the pregnancy — led to a baby's suffering, as evidenced by testing of the newborn.
Haslam has until Tuesday to decide whether to sign or veto the criminalization bill. If he does nothing, it becomes law. However, this criminal law would be unusual because it comes with a "sunset" provision. That means lawmakers would need to examine its impact again in two years and decide whether it should remain.