Lisa M. Cleveland, PhD, APRN, CPNP-PC, IBCLC, FAAN, professor in the School of Nursing at The University of Texas Health Science Center at San Antonio (UT Health San Antonio), a Certified Pediatric Nurse Practitioner and an International Board-Certified Lactation Consultant, whose career began in the Neonatal Intensive Care Unit (NICU), had dreamed of becoming a nurse for as long as she can remember.
“I felt truly privileged and challenged by caring for such tiny and vulnerable babies and the families who loved them. I saw firsthand the stress and challenges families faced daily — a phenomenon that would later become the topic of my dissertation research at The University of Texas at Austin,” Cleveland said.
Joining UT Health San Antonio and earning her PhD in Nursing Research
Cleveland, who joined UT Health San Antonio shortly after her family arrived in San Antonio in 2004, is the proud spouse of a retired U.S. Army Nurse Corps Officer who retired from Brooke Army Medical Center in 2009. At the time of his retirement, with her family comfortably settled in San Antonio with their son, who was 10 years old at the time, Cleveland was enjoying teaching and was only one year away from graduating with her PhD in Nursing Research from UT Austin.
“My dissertation was focused on the experiences of mothers who had infants in the NICU,” Cleveland said.
“I collected all my data in San Antonio and got to know the city well. I met many mothers whose infants had been in the NICU for something called neonatal abstinence syndrome (NAS), a withdrawal syndrome infants can experience if they are prenatally exposed to opioids, such as prescription painkillers or heroin,” she said. “As a NICU nurse in Houston in the early 90s, I had cared for a few infants with NAS, but I wasn’t prepared for the large number of infants with NAS in Bexar County when I collected the data in 2010.”
With a bit more research, Cleveland learned that a third of all NAS cases in Texas occurred in Bexar County, amounting to 300-400 families personally impacted in the community each year.
Seeing the opioid crisis unfold
Cleveland also learned that, while the NICU experience was stressful for all mothers, the mothers of infants with NAS faced additional challenges and barriers to parenting, such as stigma and discrimination.
“I found their stories so compelling that when I finished my dissertation, I knew I wanted to work exclusively with families impacted by NAS and to learn more about how nurses could better support them,” Cleveland shared.
To better understand the needs of families affected by NAS, Cleveland applied for and was awarded a Patient-Centered Outcome Research Institute grant to establish the Bexar County NAS Collaborative (BCNC), whose mission is to support individuals and families in the community personally impacted by NAS through collaborative education, research and clinical practice.
“At the core of this collaborative are the families we serve, and our work is driven by the outcomes that matter to them,” Cleveland said. “For example, during a community conversation sponsored by the BCNC, families told us that San Antonio lacked recovery support housing where women could live with their children while accessing substance use treatment and recovery services. With further exploration, I discovered that 70% of women with substance use disorders have young, dependent children, but very few recovery residences nationwide provide beds for women and children. Further, when women remain with their children during treatment, they are far more likely to successfully complete treatment and achieve long-term recovery.”
Cleveland also learned that the current U.S. opioid crisis has resulted in a national welfare crisis.
Between 2012 and 2016, there was a 10% increase in children entering foster care after more than a decade of sustained decline. Additionally, in the six states hardest impacted by the opioid crisis (Alaska, Georgia, Minnesota, Indiana, Montana and New Hampshire), there has been a 50% increase over the same four-year period. To address this need to keep families together, Cleveland’s team submitted a proposal to the Texas Health and Human Services Commission and received funding to establish a recovery residence for women and their children in San Antonio.
Casa Mia gives hope to women and their families
Casa Mia, which opened in December 2018 and is located in the beautiful Monte Vista neighborhood in downtown San Antonio, is a partnership between the UT Health San Antonio School of Nursing and the local non-profit, Crosspoint, Inc.
“With a capacity to house 20 women and children, completely free of charge, Casa Mia is helping our community take an active step toward ending the intergenerational cycle of trauma that occurs with early separation of mothers from their children,” Cleveland said. “Crosspoint brings their years of expertise in recovery support housing and community re-entry to Casa Mia. The School of Nursing brings our vast experience in women’s and children’s health and wellness, nutrition and developmental support services.
Due to the success of this care model, the School of Nursing has been awarded additional funding to replicate Casa Mia in two other Texas communities — Fort Worth and Corpus Christi — and expand the San Antonio program to a new Women’s Wellness Campus that will be located on the city’s east side. The new campus will have a Casa Mia program with double the current capacity (40 women and children), a primary care clinic operated by UT Health San Antonio School of Nursing and a specialized NAS Center where infants with NAS can recover with their primary caregivers in a home-like environment while being supported by 24-hour nursing care.
The future of substance use disorder research
Overdose death is the leading cause of injury death for adults in the U.S. Overdose is also a leading cause of maternal mortality in Texas and a growing concern nationally, having doubled over the past several decades. These numbers continued to climb during the pandemic as people were isolated and many requiring treatment and recovery support services could not access them.
“We had to be very creative at Casa Mia to ensure the families we serve continued to have access to the recovery support services they needed,” Cleveland shared. “The pandemic forced us to think outside the box and create new ways to connect virtually, which was well received.”
Cleveland, a national expert on opioid use disorder, has hope that the future of substance use disorder (SUD) research will be guided by the knowledge that SUD is a chronic human condition like so many others, such as diabetes, obesity and hypertension.
“This approach offers the potential to conduct research and learn more about the management of SUD without the stigma and discrimination that often accompanies it,” Cleveland said.
Clinical trials actively seeking participants
Recruitment and enrollment for two research studies led by Cleveland for the School of Nursing are ongoing. The Impact of Prenatal Opioid Use on the Maternal-Infant Dyad is enrolling pregnant women, new mothers and their infants, both opioid exposed and non-opioid exposed. The second study is the Maternal Opioid Morbidity Study (MOMS), which is currently enrolling women with a history of substance use disorder.