The U.S. drug epidemic is evolving – and physicians say mothers and babies may be left behind in its latest wave.

Pregnant women who are addicted to opioids often struggle to access treatment and services, and their challenges have received relatively little attention despite being a targeted group in the nation’s response to the opioid epidemic. Now, doctors say the emerging problem of polysubstance use – when people use more than one type of drug, such as opioids and methamphetamine – is being overlooked among pregnant women, with unknown long-term consequences for mothers and babies alike.

“We have put a lot of time and money and energy into opioids, which is awesome,” says Dr. Katrina Mark, an OB-GYN and medical director of the University of Maryland Medical Center’s women’s health clinic. “But we really need to have a wider view and realize that a lot of these women with opioid use disorder have polysubstance use (issues), and even the ones who aren’t using opioids are using other substances.”

West Virginia, for example, long considered an epicenter of the opioid crisis with one of the highest overdose death rates in the country, has been awarded $70.7 million in federal grants to combat the epidemic. Several hospitals have established separate neonatal intensive care units for babies suffering from opioid withdrawal, while in 2018, West Virginia became the first state approved to authorize centers that provide services for these babies and their families through Medicaid.

In 2016, the state made it easier for hospitals to track opioid exposure among newborns. The following year, 50.6 babies per 1,000 births were born with neonatal abstinence syndrome, which occurs when an infant suffers opioid withdrawal as a result of the mother’s use while pregnant, causing symptoms such as trembling, irritability and dehydration. Nationally, that rate was 7 per 1,000 in 2016, the most recent year for which data is available, according to the Healthcare Cost and Utilization Project.

But now a new trend is apparent. After surging in western states, meth-related overdose deaths have been climbing in states like West Virginia in recent years, and it’s unclear how mothers and babies have been affected.

“I think opioids are the past, or are going to be soon, because there are so many treatment programs for them that I think we’re trying to get a handle on it,” says Dr. Stefan Maxwell, pediatrics chief at Charleston Area Medical Center’s Women and Children’s Hospital in West Virginia. “Meth seems to be more of a problem, and I’m concerned because I don’t really know what that’s going to lead to.”

In addition to opioids, West Virginia recently began tracking other substances babies were exposed to in utero, Maxwell says, but it will be six months to a year before that data is meaningful. Few other states, if any, have similar tracking tools, he says.

Some data suggests the polysubstance abuse trend is occurring among mothers nationwide. Across the U.S. in 2018, 5.4% of pregnant women reported using any illegal drug in the last month, down from 8.5% in 2017, according to a federal health survey. That decrease – representing about 66,000 women – was driven in part by a 31.3% decline in the number of pregnant women who reported using opioids, from about 32,000 to 22,000. Yet pregnant women who said they had used meth doubled from 3,000 to 6,000.

A survey of nearly 16,000 people entering treatment for opioid use disorder between 2011 and 2018, meanwhile, showed an 85% uptick in the number of people who said they’d also used meth in the last month. More than 90% of people who used opioids had also used at least one other illegal drug.

“In the early newborn period, we can treat anything,” says Maxwell, former chairman of the West Virginia Perinatal Partnership. “But the problem is, what happens when they are 5, 7, 9 years of age and going into school, and they’ve been exposed to these complex amounts of drugs in utero – how did that affect their developing brain?”

Shifting drug use patterns are often first reflected in births, and pinning down the number of babies born exposed to specific substances could offer a fuller picture of the current status of the U.S. drug epidemic than the number of overdose deaths. That information gap means it’s challenging for policymakers to allocate funding and develop programs to support these newborns and their families.

“As we continually focus on the death side of (the drug epidemic), we don’t understand the living side,” says Dr. Daniel Ciccarone, a drug researcher and professor at the University of California-San Francisco School of Medicine. “The living side of it – no matter how deadly the drug is – naturally is much bigger. It’s the base of the pyramid.”

Policymakers are beginning to address the issue. The federal spending package finalized this month includes legislation that will allow states to use some of their billions in federal opioid funding to address the surge in meth and cocaine use, The New York Times reported.

The Food and Drug Administration, meanwhile, recently held a conference to discuss whether drugs could be developed to treat addiction to stimulants like cocaine and meth. Medication-assisted treatment – a combination of counseling and medication that blunts withdrawals – is the standard treatment for opioid addiction, and providers currently rely on behavioral therapies alone to treat other substance use disorders.

“With opioids, you have medication-assisted treatment, which is great, and it works really well,” Mark says. “It is effective, it is safe and we have good protocols for how to do that. But with a lot of the other drugs, like cocaine and methamphetamine, we don’t have that, and so we’re sort of lagging behind on exactly how to treat for those things.”

Addiction treatment for mothers is lagging in general. Just 19 states have drug treatment programs specifically for pregnant women, according to the Guttmacher Institute, and it’s not always accessible. Across West Virginia, Kentucky, North Carolina and Tennessee in 2017, opioid addiction treatment providers were less likely to take a new patient if she was pregnant, according to a Vanderbilt University study.

Some opioid treatment programs, meanwhile, kick women out if they test positive for other substances, while stigma or fear of legal repercussions may also keep women from disclosing their drug use to providers. In 23 states, substance use during pregnancy is considered child abuse, according to Guttmacher.

“I understand why those policies exist, but it also becomes a really big problem in that people that have polysubstance use can’t find good treatment sometimes,” Mark says.

Screening women for drug use and helping them find accessible treatment early in – or before – pregnancy could help curb the number of babies born affected by substances like opioids or meth, Mark says. And Ciccarone notes that mothers and children should be one focus of a comprehensive plan to address the ever-shifting drug use patterns in the U.S.

“All of a sudden, there’s a small wave of affected babies, and, of course, that makes us concerned,” Ciccarone says. “But it’s part of the whole thing – that’s why we call it a crisis, because there’s a lot of moving parts and a lot of places to be concerned about.”