The thought of a newborn in withdrawal is heart-wrenching. I know better than most; my eldest daughter went through a month and a half of opioid withdrawal after I gave birth to her while taking methadone. I remember the abysmal feeling of guilt that came with following my doctor's orders. I felt helpless to soothe her pain.
The statistics are grim. Every 25 minutes, a child is born in the United States dependent on opioids—a dependency that can cause their first days of life to be spent shrieking in pain, limbs trembling within the cold confines of their plastic NICU cribs, eyes squinting against the harsh lights above.
But what if much of what we know about addiction care during pregnancy, and the protocol followed by the majority of treatment centers and hospitals, is outdated? Loretta Finnegan, executive officer at the College on Problems of Drug Dependence, an organization dedicated to advancing scientific knowledge about addiction, first began treating opioid-dependent babies in the mid-’70s. She developed the scoring index—often called the Finnegan Score—that most United States hospitals use today to determine the severity of neonatal abstinence syndrome (NAS) in infants born to mothers on methadone and other opioids. High scores often mean a trip to the neonatal intensive care unit (NICU), but Finnegan doesn’t believe that’s always the best solution.
"The babies don't need to be in the Neonatal Intensive Care Unit for NAS," she tells me. Allowing mother and child to room together, have plenty of skin-to-skin contact, and breastfeed on demand are all methods proven to help reduce the severity and even chances of developing NAS—information backed by a 2013 study out of Children's Hospital-Dartmouth. Essentially, the mother is the person most capable of soothing her withdrawing child's pain, despite what stigma and many hospital protocols insist. Still, most babies who show signs of NAS are separated from their families and sent the to the NICU, where the bright lights, loud noises, and lack of early maternal bonding can lead to aggravated symptoms.
It's not just infant care that’s problematic. In 2012, Medicaid covered 77.6 percent of NAS-related hospital expenses, suggesting that the majority of opioid-dependent pregnant women use Medicaid. Forty-nine states cover naltrexone, the form of medication assisted treatment (MAT) favored by law-enforcement but not approved for pregnancy. All 50 states and DC also cover buprenorphine, one of the MAT options available to pregnant women, but doctors can choose whether or not to accept insurance for the mandatory visits. Buprenorphine requires a period of induction before beginning treatment, which can be difficult for women who are new to recovery. Only 36 states cover methadone, even though it has been the gold-standard of care for addiction during pregnancy since the ‘70s.
Even within those states, individual clinics get to decide whether or not they accept Medicaid. This means that if an opioid-addicted woman becomes pregnant while living far from a Medicaid-insured clinic, she will likely have to self-finance the treatment, which is expensive. If she can't do that and instead continues to use illicit drugs, she often gets written off as a "selfish junkie." She could lose custodial rights, or even face criminal charges.
I was lucky. I began methadone treatment at The Boulder Clinic (now BHG Longmont Treatment Center) in Colorado when I discovered I was pregnant with my first daughter. They didn't accept Medicaid at the time, and I was too broke to both pay for treatment and keep a roof over my head. Fortunately, a private grant covered my care. The grant was applied automatically—I was never even told exactly where the money came from, which is especially lucky because I was actively using heroin before beginning methadone treatment and may not have had the motivation to discover and apply for funding on my own. Grants like these are speckled across the country, but the fact remains that for too many people, accessing evidence-based treatment is impossible. Becoming pregnant doesn't change that.
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Even when a pregnant woman is able to start methadone treatment, she still may not receive the best care for herself and her child. John McCarthy, assistant professor of psychiatry at the University of California-Davis, who has worked with pregnant women on methadone for over 40 years, led a study that discovered splitting a pregnant woman's total methadone dose in two or more helped reduce rates of NAS to 29 percent, versus 60 percent to 80 percent of babies born to women using conventional dosing methods. This is likely due to biological changes that cause a pregnant woman to metabolize methadone at a much faster rate than normal.
This metabolic change often presents as patients who experience withdrawal in the evening or morning before dosing, followed by sedation a few hours after dosing. Another study used ultrasound imaging to discover that the flux in methadone serum levels caused fetal restlessness before dosing, and stillness a few hours after dosing—symptoms that were palpable in my late pregnancy. But I was never offered split doses. When I reported that I was feeling withdrawal in the morning, my dose was raised. When I complained of midday fatigue, the treatment staff attributed it to the pregnancy.
I began to believe that it was normal to fall asleep while sitting upright in an intensive graduate studies class. It was only years later, after being introduced to McCarthy's findings, that I realized I should have been offered split-dosing. My daughter's painful neonatal withdrawal only made me more certain that my clinic failed to provide us with adequate care. Michelle Ryan, the current program director at BHG Longmont, says that they now offer pregnant women split-dosing. "In fact, we recommend it," she adds. She tells me she’s unable to comment on the care provided before the clinic changed locations in 2014, which was after I gave birth.
Although it’s encouraging that my former clinic has updated their practices, there are still programs in the United States that continue to deny a mode of treatment proven to significantly reduce the chances of infant withdrawal. Some clinics technically offer split-dosing, but neglect to inform patients unless directly asked. Several mothers I spoke with reported being denied split-dosing for reasons ranging from blanket clinic protocol to lack of maternal sedation. But McCarthy says that the decision to offer split-dosing should not be based only on how the mother feels.
"The baby needs the [split] dose," he asserts. "The baby needs that stability. It doesn’t need to be exposed to the difference between methadone serum levels at four hours and 24 hours." So why don't all clinics provide this service?
Jana Burson, an addiction treatment specialist in North Carolina and author of the book, Pain Pill Addiction: A Prescription For Hope describes the protocol for giving patients "take-homes,” sealed measured doses that are sent home with the patient. Take-homes are often necessary for split-dosing practices, since clinics usually close around late morning or early afternoon—well before a second dose should be taken. Granting them, however, is a process that involves permissions from the State Opioid Treatment Authority (SOTA) and the Substance Abuse Mental Health Services Administration (SAMHSA). Simply put, split-dosing requires both state and federal permissions. But, Burson adds, "It’s not that complicated. We usually get it done in under 24 hours."
Zac Talbott, who owns methadone clinics in Georgia and North Carolina, thinks it's even easier. "It takes two minutes to ask for the exception," he says. When I ask why he thinks more clinics refuse this service if granting split-doses is such a simple process, he replies, "I'm sure it's rooted in one: the lack of knowledge about methadone and blood levels, and two: stigma and negative views of patients."
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