There are many people affected by opioid addiction in Vermont, but for pregnant women who are substance dependent, there are always two lives at stake.
Every healthy birth brings a maternal sigh of relief, but as she swaddles her day old baby at Dartmouth Hitchcock Medical Center in Lebanon, N.H., a young Vermont mother – who wants to remain anonymous – is probably more relieved than most.
A year ago she injured her back and a friend gave her some prescription pain killers. By the time she was pregnant, she had developed a dependency.
“It didn’t take long to go from, 'This is all right to take sometime,’ to, ‘I’ve got to do it every day,’ and then I’m puking and having withdrawal symptoms if I’m not doing it,” she says.
Babies Born With Opioid Withdrawal
Her baby is healthy, but there was a good chance she would have symptoms of opioid withdrawal, a condition known as neonatal abstinence syndrome, or NAS. The symptoms include crying inconsolably, lack of appetite, sleeplessness and hyperactivity. In many cases, morphine is used to treat NAS infants.
The mother was able to get help during her pregnancy at the new Dartmouth Hitchcock Perinatal Addiction Treatment Program.
The 17 women currently enrolled in the program have access to medical, counseling and treatment services that until recently weren’t as readily available. Before the program opened last summer, treatment was sometimes difficult to access and counseling and other services were scattered and uncoordinated.
"Prior to this program opening, [there] was the sense of frustration that our patients, if they were brave enough to come forward ... were then being told, there's really nothing we can do to help." - Daisy Goodman, Dartmouth Hitchcock Perinatal Addiction Treatment Program
“That was the hardest thing for us prior to this program opening, was the sense of frustration that our patients, if they were brave enough to come forward – and it takes an enormous amount of courage to come forward and ask for help – were then being told, there’s really nothing we can do to help,” says nurse midwife Daisy Goodman.
Jennifer, who’s one of Goodman’s patients, is due to have her baby soon, but she became pregnant before the Dartmouth Hitchcock program opened. At that time she says she couldn’t get into a treatment program.
“I was making phone calls to different places and nobody would take me because of the insurance reasons,” she says.
A Changing Approach To Care
Caregivers say Jennifer is typical of a substance dependent pregnant woman who becomes pregnant. She wanted help.
“I didn’t know what to do. I didn’t want to hurt my baby or myself, and I was doing both,” says Jennifer.
The Dartmouth Hitchcock clinic and a longer running program at Fletcher Allen Health Care represent a changing approach to caring for women who are taking opioids during pregnancy.
Recognizing the nature of the disease of addiction and the complex factors at work in the lives of the women affected, the approach involves integrated counseling, drug treatment and medical services, delivered as much as possible in a single location by a doctors, nurses, counselors and social service workers all in close communication.
The approach is still a work-in-progress and there are challenges.
At Fletcher Allen Health Care in Burlington, pediatrician Dr. Anne Johnston has for the past 12 years helped build a program for Vermont mothers and infants with opioid exposure.
Overcoming Stigma
Johnston says one hurdle was changing caregiver attitudes toward the mothers.
She says there’s been progress. But, "there is still a fair amount of judgment out there that these women are morally inferior and that they’re dumb. That couldn’t be further from the truth, and this just drives the rift between medicine and these families even deeper.”
"There is still a fair amount of judgment out there that these women are morally inferior and that they're dumb. That couldn't be further from the truth, and this just drives the rift between medicine and these families even deeper." - Dr. Anne Johnston, Fletcher Allen Health Care
Fletcher Allen treats about 130 substance dependent mothers and their babies each year.
Unlike other facilities like Dartmouth-Hitchcock, which keep infants hospitalized for two weeks or more when they need treatment for neonatal abstinence syndrome, Fletcher Allen releases them to the care of their mothers, who administer methadone used to wean the infants from opioid dependency.
The idea is to hasten and strengthen the attachment between mother and child, and also cut costs in an era of closely scrutinized hospital budgets.
Monitoring Take-Home Methadone
But Fletcher Allen’s approach raises concerns about misuse of the take-home methadone.
“We have a lot of safeguards in place,” Johnston says. “We have not found to our knowledge that the parents are using the methadone that the baby is prescribed.”
Johnston says a greater worry is that parents might give a fussy infant extra methadone. There has been one instance of this, but she says otherwise Fletcher Allen has overseen this method of NAS treatment for more than 300 babies in the past 12 years with no apparent problems.
Unlike alcohol abuse during pregnancy, opioid use by a pregnant mother does not seem to have a long term impact on child development.
Johnston says the hospital follows the progress of all opioid exposed infants, not only those needing treatment.
A study conducted by the Centers for Disease Control and Prevention has found that babies born to women taking prescription pain killers just before or during early pregnancy are at a modest risk of birth defects.
But Johnston says unlike alcohol abuse during pregnancy, opioid use by a pregnant mother does not seem to have a long term impact on child development.
Additional Risks
Johnston says more than 90 percent of pregnant women who use opioids also smoke, which poses a health risk to both mother and child. Withdrawal symptoms in newborns can be more severe if the mother is a heavy smoker.
While pregnant women are put at the front of the line for treatment, their partners who are using opioids are not, which poses an added challenge for mothers.
Factors like poverty, depression and family dysfunction also affect a child’s long term development.
Those factors, combined with the stress of having a newborn and the need to find transportation and daycare to attend counseling, increase the risk of a mother’s relapse after a child is born.
While pregnant women are put at the front of the line for treatment, their partners who are using opioids are not, which poses an added challenge for mothers.
Johnston says there are difficulties maintaining treatment “a fair amount of the time” after a child is born. This is a period providers say needs more attention.
“From my standpoint, I am most concerned about the care of these women right after they deliver,” says Fletcher Allen obstetrician Dr. Marjorie Meyer.
Post-Partum Care
“During their pregnancy it’s ‘All hands on deck,'" Meyer says. "I think moving forward, trying to understand what’s happening to these women post-partum is really key.”
Gloria Varagallo, substance abuse clinical care coordinator for Howard Center and Fletcher Allen agrees.
“From what I can see, the people coming back for the second or third child on treatment, somewhere after they delivered, care got dropped; they weren’t doing counseling, they stopped the medication, they couldn’t find a provider, things got too hard,” says Varagallo.
As she prepares to return home with her newborn, the mother at Dartmouth Hitchcock says she’s worries about relapsing and using opioids again.
"Having other kids at home, the stresses of a new baby, and also the stresses of being a mom of three. It used to be a coping mechanism for me. It was like my 'mom time', you know, time for me."
“Having other kids at home, the stresses of a new baby, and also the stresses of being a mom of three. It used to be a coping mechanism for me. It was like my ‘mom time’, you know, time for me,” she says.
She’s hopeful she’ll find other ways to cope now that she’s getting counseling and she’s befriended other women at the Dartmouth Hitchcock program.
Cathy Milliken, who directs the program, says her center is working to try to provide more support to mothers after their children are born.
“We’ve started a partnership with some of the early intervention folks about how they can be connecting with our women. They often fall through the cracks after giving birth,” says Milliken.
Preventing Relapse
Fletcher Allen’s Dr. Marjorie Meyer says it’s important to recognize that relapse is part of a chronic disease like addiction.
“It’s not treating strep throat. You do well for periods of time and then your disease is not so well controlled for a period of time," Meyer says. "It doesn’t mean you’re bad people, it doesn’t mean that you’re not interested in getting better, it doesn’t mean that you’re not interested in being a parent. It’s the nature of the disease that you have.”
"It doesn't mean you're bad people, it doesn't mean that you're not interested in getting better, it doesn't mean that you're not interested in being a parent. It's the nature of the disease that you have." - Dr. Marjorie Meyer, Fletcher Allen Health Care
Dartmouth Hitchcock and Fletcher Allen also work with other hospitals in Vermont and often treat infants born elsewhere who need a higher level of NAS care.
Many of those hospitals are collaborating with other local services to provide care to pregnant mothers with drug dependency problems. Some have come into being only recently, so services vary and help is not as easy to access in every part of the state.
The services are part of the state’s “Hub and Spoke” model of treatment, based on establishing centralized facilities that work with smaller community based services to provide comprehensive treatment.
These collaborations are key to dealing with pregnant women with opioid dependency.
“This particular problem is more challenging because it requires so many different systems working together well," says Vermont Health Commissioner Dr. Harry Chen. "The social service system, the health care system, the substance abuse system and even, to some extent, the corrections system."
This story is the second in a three-part series examining what's being done to care for pregnant women and mothers with opioid addiction. Listen to Part 1 here and Part 3 here.