When Anne’s baby boy was born at Eastern Maine Medical Center, his little body began a painstaking withdrawal from narcotics. In his first days of life, the infant unwittingly craved the methadone his mother began taking during her pregnancy to help her kick an addiction to prescription painkillers.
Doctors administered tiny amounts of methadone, a synthetic drug that blocks the effects of opiates, to the newborn, along with another medication to prevent dangerous seizures, as part of a delicate process to wean him off the drug.
Medical personnel kept a close eye for telltale tremors, twitching, persistent cries, watery stool and other signs of neonatal abstinence syndrome, a group of symptoms babies experience while withdrawing from exposure to narcotics.
A month later, the baby boy remained at the hospital. He no longer needed methadone, and while he still struggled to sleep, he ate well and grew healthier. Anne spent most of her days at nights at the hospital, holding and soothing her son through the last stages of his withdrawal.
“He definitely is a momma’s boy,” Anne said. “He likes my comfort and when I’m not around he cries a lot.”
Anne, 31, of Old Town spoke on the condition her real name not be used. She feared she’d be judged as a bad mother for using methadone, though the treatment was safer for her son, born June 6, than continuing her three-year addiction to Percocet, she said.
Doctors warn addicted mothers against quitting narcotic drugs cold turkey, which can endanger the baby and potentially lead to miscarriage. As Anne’s physician, Dr. Mark Brown, said, “If she cuts down or stops, she’s going to go through withdrawal, and whatever she feels the baby feels.”
While newborns can experience withdrawal when their mothers take methadone or other replacement drugs such as buprenorphine, the symptoms typically are milder than with street drugs or prescription painkillers.
“I actually think that I’m a better mom for doing [methadone],” she said. “Not everybody thinks that way.”
Anne’s baby boy, who recently was discharged from the hospital, was one of nearly 400 infants born in Maine this year exposed to drugs in the womb. As prescription drug abuse has spiked in Maine — claiming more lives than car accidents each year — babies have suffered a share of the burden.
In 2012, 779 babies were born “drug affected” in Maine, according to the Department of Health and Human Services. That’s nearly five times the total of 165 babies in 2005.
Hospitals are required by law to report suspected cases of newborn drug exposure to DHHS.
Medical providers are careful to note the babies aren’t “drug-addicted.” Addiction involves a pattern of behavior that infants are incapable of, including seeking a high, they say.
A few years ago, experts were just trying to keep up with the problem. Today, research based in the Bangor area is fueling new thinking about how to best treat drug-affected babies, including whether they belong in hospitals for sometimes weeks on end.
The tiny newborns, as they struggle to thrive inside intensive care units kept dim and quiet to calm them, also raise big questions about costs to the state’s cash-strapped Medicaid program and even the intractable nature of poverty.
Home or hospital?
Brown, the EMMC pediatrician and neonatologist who cared for Anne’s baby, has worked for the last seven years with UMaine psychology professor Marie Hayes to study the health of drug-affected babies. That research, combined with Brown’s day-to-day care for the newborns, has led him to believe that many of the babies could be better cared for at home with regular visits to an outpatient program, if one existed in Maine.
Drug-affected babies spend at least five to six days at the hospital, but can stay up to three weeks or more. Some may experience few, if any, symptoms, while others may resist eating or convulse with tremors, among other effects. Medical staff examine each baby, assigning them a score that measures the severity of withdrawal and determines whether the infant requires medication.
The first line of treatment, called “comfort care,” involves simply holding the baby in a quiet environment. If that’s enough to get them through withdrawal, the babies can go home, with the blessing of DHHS, Brown said.
The department typically doesn’t remove children from mothers receiving replacement medication such as methadone solely because the baby is born affected by the drug. If a mother is in treatment and can provide a stable home, the baby may remain in her care. DHHS will order a review by the child welfare unit if allegations of abuse, neglect or other concerns arise.
Babies with more severe symptoms may be treated with methadone and other medications, though doctors try to avoid it, Brown said. There is no universally accepted standard of care for the babies, with research in the area still in its early stages.
If a baby’s home is safe, it’s the best setting for recovery as long as a strong social safety net — like an outpatient program — is in place, Brown said. Maine lacks such a program, though they’ve proven successful in Vermont, Ohio and other states, he said. Brown is working to establish an outpatient program in the Bangor area within the next year, but has struggled to find funding.
“I think it’s best to keep the family together, and the hospital imposes an artificial environment that makes it a little more difficult for the mothers to be successful,” he said.
Establishing the program requires not only money but also pharmacy, case management and social work components to be successful, Brown said. Some mothers may relapse into addiction, and the community has a responsibility to help them if the babies are to have a fair chance at a healthy life, he said.
“I want to work toward a better program here,” Brown said. “I think using an acute care bed in a hospital is not the best place to have the full treatment for a baby who’s going through withdrawal.”
More care, more costs
Hospital care is also expensive. At EMMC, which treated 183 babies exposed to opiates last year, the newborns’ average hospital stay was 21 days, costing an average $32,016.
Portland’s Maine Medical Center treated 36 drug-affected babies over the last three months.
Most of the tab was picked up by MaineCare, the state’s Medicaid program. Brown estimated that 98 percent of the mothers of drug-affected babies treated at EMMC are covered by MaineCare.
Maine DHHS could not provide figures for how much MaineCare spends on treatment for drug-affected babies, but studies show the costs far exceed hospital expenses for healthy newborns.
Nationally, state Medicaid programs cover the health costs of 78 percent of newborns diagnosed with neonatal abstinence syndrome, according to a University of Michigan study. The study found in 2009, one baby per hour was born drug-affected in the United States. Between 2000 and 2009, the number of babies born experiencing drug withdrawal increased nearly threefold, while the cost of health care for those babies nearly quadrupled from $190 million to $720 million.
At EMMC, the primary drugs babies are exposed to are opiates, such as OxyContin and Vicodin, and benzodiazepines, a class of common psychiatric medications that includes Valium and Xanax. Brown said he sees babies affected by bath salts, a synthetic drug that exploded in the Bangor area in recent years, “sporadically here and there.”
Most of the babies are affected by a replacement opiate, with mothers in treatment programs using methadone or buprenorphine, Brown said. About 15 percent have been exposed to prescription medication and 10 percent to illicit drugs, he said.
“We really make a strong effort to try to reach out to those moms who are going to deliver so that we can prepare them for the possibility that their baby will receive treatment for withdrawal,” Brown said.
Researching the options
Some recent research conducted by Brown, Hayes and others, published in the Journal of the American Medical Association, has shed light on how a baby’s genetic makeup may affect the response to withdrawal.
Babies with a certain genetic variant associated with opiate addiction were, counterintuitively, better able to tolerate withdrawal. Those babies may be more likely to be vulnerable to addiction as they grow up, but their first days in the hospital were more tolerable, a finding that could lead clinicians to potentially consider less aggressive treatment.
The researchers also studied another genetic variant known for putting people at a higher risk for certain psychiatric diseases. Among opiate-affected babies, the variant was associated with less severe withdrawal.
Now, researchers are conducting a clinical trial to examine whether the genetic variants affect how well babies respond to replacement drugs, Hayes said. She and Brown have theorized that babies exposed to methadone prenatally may be best treated with the same drug, rather than other common replacement drugs such as morphine.
“Withdrawing from a drug that is identical to the one of exposure may be safer than starting a different opiate,” she said.
While genetics provide clues about a biological predilection toward addiction, a baby’s home environment is a far bigger factor in their future health, Hayes said.
Many drug-affected babies leave the hospital and get very little follow-up care, she said.
Their mothers may also smoke and abuse alcohol, as well as struggle to stay afloat financially.
“It’s really poverty and the effects of the environment that overwhelm the babies’ risk,” Hayes said. “The opiate exposure is one factor … A progressive and supportive postnatal environment is the most important thing, and these babies don’t have that.”
For medical providers, passing judgement on pregnant mothers with addiction problems serves no one, according to Brown.
“You can’t have contempt for someone and be effective as a caregiver … I really feel like as a health care professional this is a population that we have to meet in the middle,” he said. “There’s a generation that needs to be cared for and the people that are primarily caring for them are the parents and the community that’s around us. That’s our job. It’s not something that any judgement will change, I think it only gets in the way.”
Motivated by her pregnancy to get help, Anne said she has found methadone treatment helpful, though watching her son struggle through withdrawal has been difficult. Nine months in, she said she feels much more stable and able to care for her newborn boy and her other four children, ages 15, 11, 7 and 3.
“I feel more myself now, I feel I can give my kids more of what they need,” she said. “I think more clearly now.”
She once counted herself among those who misunderstand methadone and the benefits it offers, she said. Many people think methadone is just as harmful as abusing painkillers, she said.
“Honestly, I did, too, until I got more information about it and I learned more about it and got it myself,” Anne said. “Being in the situation now, I know how much more it helped me than staying in the lifestyle that I did.”