Transcript follows: When a pregnant mother shoots heroin or pops prescription painkillers, the tiny baby inside of her can grow dependent on the drugs, too.
As the number of individuals addicted to opioids has surged in recent years, so has the incidence of neonatal abstinence syndrome, or N.A.S. — tripling over the decade ending in 2009. The cost of caring for these infants has skyrocketed as well, up to $1.5 billion in 2012, with about 80 percent of that tally paid for by Medicaid.
Dennis Welsh, CEO of tiny Down East Community Hospital in Machias, Maine, was dismayed at the frequency of such births after coming aboard as chief executive. More than a quarter of babies born there suffer from NAS.
“What we found is that roughly 27 percent of all our babies born show signs of withdrawal,” Welsh says. “Mostly, the urine toxicology is showing that they are from opiates, which seemed to be phenomenal. Trying to detox that child can be very complicated and a lot of these patients are transferred to a tertiary care medical center that we work with and they end up in their NICU, their neonatal intensive care unit. So, for me, socially, this is a staggering, sad story.
“The addiction is so powerful and the availability of these drugs is so remarkable that it’s really a plague. You take it a step further when you’re a pregnant mom and you’ve got a young child growing in you and you’re passing that addiction on to them to the point where they need to be detoxed in their first days of life. It’s kind of disheartening.”
Across the country, hospitals are seeking new ways to address this issue. Legislators, too, have taken notice, with Congress passing the Protecting Our Infants Act this past November, directing federal agencies to gather and share best practices on how to treat the syndrome.
As part of this legislation, the Substance Abuse and Mental Health Services Administration, or SAMHSA, is now working to review any current planning and coordination related to opioid use by pregnant mothers. The agency, which is a division of the Department of Health & Human Services, is also developing strategies to address gaps in research about NAS, and any duplication among federal programs. Those findings are due in November.
One key barrier to care for these mothers, SAMSHA has found, is the stigma that some doctors or nurses might feel when presented with a mother using while pregnant, says Sharon Amatetti, public health advisor in SAMHSA’s Center for Substance Abuse Treatment. Providers must overcome that in order to treat these mothers.
“So, there’s a lot of fear and misunderstanding about what will happen if a woman reveals that she is using opioids, so there’s a lot of shame and stigma that women don’t feel comfortable revealing to their providers, to their OB-GYNs or anybody providing prenatal care to them that they’re even using,” says Amatetti. “So, that’s a big barrier just from the get-go, so disclosing fear that she will either be treated poorly or will not be offered treatment or that she will have involvement in a negative way with child welfare after her baby is born, that her baby might removed, those are some pretty significant obstacles.”
Instances of NAS vary geographically, with rural areas like Maine or Appalachia hit hardest. Tennessee, in particular, has been ravaged by prescription drugs, with the number of babies born dependent on them increasing sixteenfold, according to one estimate. As such, researchers in the Volunteer State are seeking new ways to limit health care costs for this particular patient population.
The typical approach to treating NAS is to wean a newborn off opioids after he or she is born. Some fear that doing so before delivery could lead to premature birth, fetal distress or even death of the baby. But one recent study from the University of Tennessee Medical Center aims to dispel the risk to the fetus in detoxifying mothers before birth.
What researchers with UT Medical found was that detoxing mothers does not harm the baby, as previous outdated studies from the ‘70s had concluded, says lead author Dr. Craig Towers. Trying such a new approach could save tens of millions in health care costs, theorizes Towers, who is also a maternal-fetal medicine specialist at UT. With about 1,000 NAS cases each year at an average cost of more than $60,000, Tennessee is paying $60 million annually to treat these infants.
One thing that was clear from this new study, Towers says, is the importance of behavioral health treatment after a pregnant mom is detoxified from opioids. In the study, about 70 percent of babies were born with NAS when a mom did not have such behavioral health follow-up care after detox. That rate stood at about 17 percent with follow-up care, the study found.
“I think the key is that we’ve shown that detox is not harmful, but if you do it, you have to have the behavioral health component,” Towers says. “You just can’t detox and then pat them on the head and send them out the door.”
UT Medical Center has been working with others to help spread some of these findings across Tennessee. One such organization it’s been working with is the Dayspring Family Health Center, a primary care and obstetrics provider in Central Appalachia. One of Dayspring’s clinics is located in the East Tennessee community of Jellico, which has the highest rate of NAS births in the entire state.
Working together with the Blue Cross Blue Shield of Tennessee Health Foundation, they found that there was a lack of access to inpatient detoxification services for childbearing women suffering from opioid addiction, says Dr. Geogy Thomas, chief medical officer of Dayspring. By fall, Dayspring hopes to roll out a new inpatient detox unit for these mothers, whom he’s seen spiral out of control without a place to stay and without comprehensive treatment services while attempting to kick their habit.
“So, in our community, we are noticing that a third of our OB patients have some sort of substance exposure during pregnancy, and then half of those kids end up withdrawing from drugs and experiencing NAS,” Thomas says. “Our whole idea is a comprehensive look at this. I think what’s happening is that a lot of people have caught the detox bug and President Obama has made that a priority, which is great. I applaud that, but I think people are catching the detox bug, but I don’t think we’re addressing this as comprehensively as we need to. We need to address not just stopping the drug — anyone can stop the drug — but the problem is how do we stop the drug and then keep them off of it and address the needs of this very difficult community and population?”
Outside of Tennessee, researchers are seeking other, less costly ways to try and treat this infant patient population. The Boston Children’s Hospital and Boston Medical Center Combined Residency Program, for one, found in another recent study that increased contact between mom and her newborn immediately after birth helps to decrease the symptoms of NAS. Those can include tremors, loss of appetite, vomiting, diarrhea and insomnia.
Lead author Dr. Mary Beth Howard says it’s clear that such increased contact between baby and mom has helped to lessen those symptoms. Such a non-pharmacologic approach to treating opioid-dependent babies also may have an added benefit of helping moms to kick their drug habit. She believes providers should seize on this moment to help change the life of the mother as well.
“This is a critical time not only in the infant’s development, but also in the mom’s path to sobriety and I think if you’re ever going to intervene for someone who’s struggling with addiction, the birth of a child is an incredibly motivating event, and so harnessing that and using that not only to improve the health of the mother, but if the mother is healthy, the baby is going to have a healthier childhood. Keeping that in mind and in focus, I think, can help,” Howard says.
