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In the early 2000s, very few hospitals in the United States specialized in neonatal opioid withdrawal treatment (generally called neonatal abstinence syndrome, or NAS). Outside of research hospitals in large population centers, such as Thomas Jefferson University Hospital in Philadelphia and Johns Hopkins in Baltimore, there wasn't a demand for such a niche specialty. In 2000, there were fewer than 3,000 cases nationwide for neonatal opioid withdrawal; in 2012, that number had skyrocketed to 21,732. Today, the opioid addiction epidemic has created a crisis in hospitals across the country. Hotspots for babies born to mothers using opioids include the rural northeast, Florida, and Appalachia. Everyday doctors and nurses have had to figure out best practices for treating these babies, as well as how to best help the mothers who may find themselves in legal trouble.
Michelle Ehrlich was working at Thomas Jefferson hospital in the early 2000s studying neonatal opioid withdrawal right when this became a nationwide issue (she now works full time for Mount Sinai in New York City). She recently co-authored an article in the New England Journal of Medicine about best practices for treating NAS. Her team hopes hospitals across the nation will embrace their findings: Treating NAS with buprenorphine instead of morphine dramatically reduced length of time babies needed to be treated (tapering dosage) and decreased hospital stays for the infants, too.
This all began when Ehrlich saw an increasing number of babies born to mothers successfully treated with buprenorphine for addiction. She thought it strange to treat the neonatal withdrawal solely with morphine or methadone. "We had babies coming in who had been exposed to buprenorphine [in utero]," says Ehrlich. "If they experienced withdrawal, we put them on morphine, which was standard practice. I thought we were going backwards in treatment from partial agonist to full agonist."
Buprenorphine is a partial agonist opioid, which means it does not fully bind to the brain's opioid receptors. Morphine and methadone are strong agonists, which makes them more powerful and addictive. Buprenorphine doesn't produce the same high as morphine, which makes it less addictive physically and mentally. The drug still satiates the addicted body's desire for opioids, but creates fewer problems. This is what makes it a preferable treatment for mothers with addiction. Ehrlich hypothesized that the same might be true for babies—especially if they'd already been exposed to buprenorphine in utero.
Ehrlich refers to a growing, but not fully embraced, practice of treating pregnant women addicted to opioids with buprenorphine. The standard course of treatment involves stabilizing and sometimes reducing opioid addiction in women during pregnancy. Stabilizing the pregnant woman's opioid intake is often the optimal route, because quitting can be more dangerous for the fetus. Buprenorphine has been proven to be safer than methadone; however, the patient often misses the high, which can be counterproductive to enticing them to quit. Fortunately, since a newborn doesn't have the psychological addiction to strong-agonist opioids, buprenorphine has proven a preferable route. Once Ehrlich and her team unblinded their study, the results were clear: Buprenorphine nearly halved babies' time in treatment for NAS.
The symptoms of neonatal opioid withdrawal can be quite hard to deal with for nurses and caretakers. When a baby's body starts to crave opioids, they may become tremulous. They usually have gastrointestinal problems, and will have diarrhea that leads to dangerous dehydration. They also develop a high-pitched scream that can be heartbreaking for caretakers to hear. Hospitals use what's called the Modified Finnegan's NAS Score Sheet, which tracks and scores these symptoms day and night to determine what doses of opioids to give the infant and when.
Still, non-pharmacological interventions are preferred as the first course of action. These include keeping the infants in dark, quiet rooms, as they are easily disturbed, which can exacerbate symptoms of withdrawal. Swaddling the babies tightly also helps reduce withdrawal symptoms. When these treatments fail to soothe the baby, then they are given opioids. The smallest dose possible is administered first, and then the baby is monitored to see if their withdrawal symptoms lessen, or at least even out.
Ehrlich says one of the problems facing this field of study is the lack of standardization for care. Each hospital has had to come up with their own set of guidelines for treating neonatal opioid withdrawal, since this is such a new field. Everyone uses the Finnegan's scale, but each hospital makes their own decision on where to draw the line and administer drugs. Ehrlich says there isn't even standardization in what drugs are used. Morphine and methadone are the most common. Some hospitals try to use non-opioid drugs; however, Ehrlich says those haven't proven to be an effective course of treatment.
Ehrlich says studies point to close contact with the mother as a way to reduce withdrawal symptoms. Unfortunately, this isn't always possible when the mother may have legal, personal, and familial problems of her own, which can prevent even supervised care. Sometimes the best course of action, for mother and child, is for patience while the doctors make choices that are in the best interest for the baby.
At Mount Sinai Hospital in New York City, one young mother struggled to have the patience necessary to even hold her child. "After my son was born, the first time I saw him was in a picture. I was released the next day, but he was in the NICU for 31 days. I had a lot of hope he'd be coming home with me. A lot of women have that. It was a huge struggle," says Randi Smith, a patient at Mount Sinai, who asked to have her named changed to protect her privacy.
Smith, a college-educated Italian American from New York, found herself in an abusive relationship in her mid 20s. Broken nose. Fractured eye. Doctors gave her Percocet, which eventually became OxyContin as a way to numb the physical and emotional pain. After years of this, she decided to go to a methadone clinic and stop misusing the drugs. That's when she found out she was pregnant—with her abuser's baby. Rather than quit methadone, she decided to stay on it while she was pregnant, which she was advised was the safest option for her baby. She bounced around several Manhattan hospitals until she found Mount Sinai, which she says accepted her without judgement. She admits stigma from hospital staff was hard to deal with, and she addressed it by staying attentive to the doctors and heeding their advice.
"I'm happy I made the choice to stay on methadone and be patient and let my son get the help he needed," Smith says. "As long as you're doing what the doctors are telling you, you're in good hands. There is a stigma, and you will have to go through dirty looks and whispers because they know who you are. It wasn't until the nurses saw me watching and waiting for my baby that they trusted me."
Once her son was released from Mount Sinai, she lived in a shelter until she was able to get back on her feet. The courts granted her custody of her son; however, she is still on methadone treatment. She reports that her son is healthy, growing, and doing very well amongst his peers.
Unfortunately, her case may be an anomaly in the bigger picture. In places across the country, women are criminalized for giving birth while using opioids (or other drugs). High courts in Alabama and South Carolina have interpreted existing child endangerment laws to prosecute women who use drugs during pregnancy. In 2014, Tennessee passed a stringent Fetal Assault Law which allowed for the prosecution of drug misuse during pregnancy as aggravated assault. The bill was allowed to lapse in 2016 because women with addiction were so afraid, they did not seek healthcare, which lead to increases in health problems for both mothers and children.
According to Lynn Paltrow, executive director for the National Advocates for Pregnant Women (NAPW), drug-using pregnant women can be criminalized just about anywhere in the country, if local prosecuting attorneys twist up the laws. Sometimes if women aren't harmed by the criminal system, the civil system (Child Protective Services) will. Even if the mother does everything asked of her, if her child is born with NAS, she can be prosecuted. NAPW fought to overturn this type of legal trickery in New Jersey recently. These types of civil prosecutions can result in loss of job or housing, and may saddle a woman with a felony conviction, essentially robbing her of ever being a mother.
NAPW wants to see these types of legal actions against pregnant women overturned. Paltrow says they are overwhelmingly used to control low-income people and people of color, and do more harm to the families involved than good. She also hopes to see more hospitals adopt policies that let the mother and child bond physically as a means to reduce NAS, including breastfeeding.
"Our recommendation is the same as the World Health Organization," Paltrow says. "And that is you should treat pregnant women like all patients. With dignity, respect, and evidence-based care."
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Update 6/30/17: This story has been updated to reflect the fact that babies in the NAS study were treated with buprenorphine compared to morphine, not morphine and methadone.