Kate clasps her hands over her pregnant belly, watching her oldest daughter play with a plastic toy at her feet. The 4-year-old puzzles over how to fit the colorful pieces together, too absorbed to notice as Kate, 31, recounts her own, more dire, struggle with opiates.
In November, Kate’s addiction landed her and most of her growing family in a sprawling farmhouse turned addiction recovery center in Windham. Comfortably furnished to feel like a home, the center — Crossroads for Women — is about 80 miles from Kate’s midcoast home.
Crossroads is the only licensed residential addiction treatment program in Maine that accepts pregnant women and allows mothers, such as Kate, to also bring their young children.
In the face of a rising number of babies born affected by drugs — 8 percent of all births in Maine last year — Crossroads is among the handful of Maine providers targeting the complicated problem of treating mothers and mothers-to-be who abuse drugs and alcohol.
Not far away, another program has sprouted up in the small town of Bridgton. There, doctors, nurses and counselors have banded together against heroin infiltrating their community, catching mothers in a net of integrated care that keeps their babies close to home.
While these programs are helping pregnant women overcome addiction, Maine recovery advocates continue to raise alarms that more treatment options are needed. Last fall’s closure of an addiction center in Westbrook drastically reduced treatment options in southern Maine, they say, and many women lack insurance to cover critical prenatal care, drug counseling and medication.
While low-income pregnant women typically qualify for MaineCare, they face hurdles in seeking addiction treatment, from shame and guilt to trouble finding a doctor, according to Dr. Mark Publicker, an addiction medicine specialist who formerly worked at the Westbrook center. Even those with MaineCare struggle to find physicians who are willing to accept their coverage and treat their opiate addiction with medication, he said.
Some women go to methadone clinics but may skip crucial prenatal medical care. Others turn to an outpatient program in Brunswick or home visits by caseworkers. Given this patchwork, Publicker suspects “there are far more women not receiving treatment in pregnancy than who are.”
A new law aimed at Maine’s drug crisis, signed Jan. 19 by Gov. Paul LePage, won rare bipartisan support. But it has drawn criticism from experts, who say it won’t do much to alleviate addiction and its allocation of $2.4 million represents a small increase in state spending on drug treatment and prevention, pegged at $76 million in 2014.
During her treatment, Kate has addressed the root causes of her addiction. Her parents were addicts, and she lacked a strong female role model, she said. She speaks of beginning to use drugs as a teenager to fill an emotional void, then finding herself relying on opiates just to get through the day.
Kate, who spoke on the condition that the BDN would not publish her full name, was 32 weeks pregnant when she entered Crossroads. Her two daughters, ages 4 and 2, came in tow. They stayed in one of five bedrooms lining a hallway suffused with natural light and teeming with the trappings of young children: baby bouncers, car seats, toys.
Her treatment included taking opiate withdrawal medication Subutex. She also attended therapy sessions during the day while the girls visit a day care right next door. With her husband in treatment for addiction at the same time, knowing she wouldn’t have to leave their daughters made the decision to get clean that much easier, she said.
“It’s not a moral decision once you’re in the grips of it,” she said about fighting her addiction. “I know nobody here woke up and decided that’s what they wanted to be in life.”
Asking the right question
Founded nearly 50 years ago to treat women with alcoholism, Crossroads has witnessed the growth of the opiate epidemic. Still, alcohol use in pregnancy remains a significant threat to the health of Maine babies.
While many other programs refuse to treat women after their second trimester because of liability concerns, Crossroads accepts women at any stage of pregnancy, along with mothers who have children under age 6, said Crossroads CEO Shannon Trainor. Last year, six babies were born to mothers in the program, she said.
She said 67 percent of women complete the program at Crossroads, higher than the national average. Their program does not provide medication for treatment of opiate addiction, so mothers who need it must find doctors to prescribe it to them during their stay, Trainor said.
The toll addiction takes on people’s lives may be indiscriminate, but for women, even more obstacles line the road to recovery, according to Trainor. Chief among them is the stigma of acknowledging their addiction. The shame and guilt, especially for mothers, is often much more profound than for “a 25-year-old guy,” Trainor said.
Then there’s the fear that acknowledging their addiction will lead authorities to take away their children. A 2014 state study of Penobscot and Piscataquis counties notes that drug and alcohol abuse was a factor in 73 percent of cases in which the Department of Health and Human Services removed children from their homes. Of the 122 children taken into state custody, 12 were babies removed at birth.
Even when a mother can keep her kids, who cares for them while she’s in treatment?
Many women also must leave home to escape a partner who abuses drugs, abuses them or both, Trainor said. But additional dangers accompany that choice, she said.
“A lot of times our women get sexually exploited,” Trainor said. “They, in not so many words, sell themselves not for money but for drugs, for safety, for sleeping on your couch one more day. We get that all the time.”
All too often, women are sexually or physically abused as children, prompting them to turn to drugs even before reaching their teenage years, she said.
“You know, if my dad’s brother sexually abused me every night, I’d probably turn to drugs too, or drinking, when I’m 11 years old to numb the pain,” Trainor said.
Those barriers to recovery at least partially explain why nearly 1,000 infants born in Maine last year were exposed to drugs in the womb. That’s the highest number on record and a more than fivefold increase since 2006.
As worrying as it is, that statistic paints an incomplete picture, Trainor said. It reflects babies born in varying situations, from mothers injecting heroin who only appear at a hospital to give birth to mothers who faithfully get treatment with medications to ease their cravings, she said.
Babies born to women treated with counseling and medication — including methadone and buprenorphine — fare much better than those subjected to the repeated binge and withdrawal episodes of illicit drug abuse, experts say. Doctors also warn addicted mothers against quitting narcotic drugs cold turkey, which can endanger the baby and potentially lead to miscarriage.
“Data doesn’t always tell the story,” Trainor said. “It doesn’t tell the story of the woman who is in a methadone treatment program and has not been using.”
The numbers also fail to capture an addiction problem that’s only now receiving the attention it deserves, according to Dr. Craig Smith, a Bridgton family physician who treats pregnant women with buprenorphine.
“It’s almost impossible to delineate whether this is an increase in the number of cases or these are people we just weren’t treating before,” he said. “We weren’t asking the question 10 years ago.”
At Smith’s family practice, located near the northern tip of Long Lake in Cumberland County, providers are asking that question. But they didn’t start screening their patients for mental health and addiction issues until the community’s heroin problem refused to be ignored, he said.
During one month roughly six years ago, several of Smith’s patients died from drug overdoses.
“I was totally unaware that they were using,” he said. “Two were 35-year-old mothers that I had seen for physicals or something like that, but I never suspected anything was going on.”
Around the same time, another patient asked him to provide her with Suboxone, but Smith wasn’t certified by the federal government to prescribe it. He suggested methadone but soon realized the 2.5-hour drive to the clinic, one way, made that option all but impossible for her.
A local drug counselor, Catherine Bell, also was becoming alarmed by rising opiate addiction among her clients. So she made a pitch to Smith: If he would get certified to prescribe Suboxone, she would provide counseling to his patients.
Smith was leery at first, worried that treating patients with drug addiction could hurt his practice. “Our misconception was that we were going to come in and it was going to be like Keith Richards in the lobby on Monday morning,” he said, “which was totally untrue.”
He and his wife and partner in the practice, Dr. Jennifer Smith, were already treating patients with addiction — they just didn’t know it, he said.
Today, Bell and others credit the Smiths with pioneering an integrated substance abuse treatment program rooted in their primary care practice. Patients see the doctors not only to get their buprenorphine prescriptions, but also for preventive medical care and treatment of depression or run-of-the-mill ailments such as sprains and colds. Pregnant women receive prenatal care.
Appointments with the Smiths at North Bridgton Family Practice are coordinated with patients’ counseling sessions at Bell’s small recovery center, Crooked River Counseling, just 5 miles down the road.
“When we work with a client, we explain to them, ‘The doctor and I are going to talk about your case all the time. We’re going to do that so that we can provide the best care that’s possible,’” Bell said. “Clients know that, and that’s the first place where they begin forming a trusting relationship that’s been lacking, most of the time, in their life.”
The moment Kate reckoned with the reality that her addiction had overcome her life came at the hands of a family member, who said — in plain terms — how selfish she and her husband had become.
“It really clicked home,” she said. “It was a hard thing to hear but it was absolutely true. We have beautiful children; they deserve a good life.”
She paused as her voice choked with tears. As she struggled to collect herself, her daughter banged loudly on the toy, trying to fit a rectangular piece through a too-small hole on the top.
“I’ve had a lot of people say, ‘Why don’t you just stop?’” Kate said over the girl’s clatter. “If it were that easy …”
But she realized she was killing her family with her addiction. She wanted them to stay together, to see her girls continue the patterns of normal life, such as their ballet and horseback riding lessons, she said.
“I still have a lot of shame and guilt, but I realized I’m a good mother,” she said, patiently showing her daughter how to insert the stubborn toy piece. “I have the potential to be a great mother. I definitely wouldn’t have seen that if I hadn’t come here.”
Close to home
In Bridgton, Bell gestures out a window in her office toward nearby Bridgton Hospital, a 25-bed facility that, despite its modest size and resources, is successfully delivering babies born to local mothers on buprenorphine.
Smith initially sent pregnant mothers in addiction treatment to Maine Medical Center in Portland, which is equipped to handle babies with neonatal abstinence syndrome, a cluster of symptoms infants may experience while withdrawing from exposure to narcotics.
But after consulting with experts in the field, he grew confident that not all of those babies needed to be admitted to a neonatal intensive care unit.
He still sends pregnant mothers taking methadone to Portland, as their babies can suffer serious withdrawal from the medication. But many infants born to mothers on buprenorphine, known under the brand name Subutex, can be safely delivered in a normal hospital setting, Smith said. Doctors and nurses watch them closely for signs of neonatal abstinence syndrome, such as tremors and seizures, transferring only those who show signs of distress.
Today, fewer than one in 10 of those babies born locally requires transfer to MMC, he said.
“The whole idea is to try to keep anybody in the community we can, because their support services are close to home,” Smith said.
Publicker describes the Smiths’ efforts as a “striking and a wonderful model,” crediting the couple for working with Bell and the hospital to provide truly comprehensive care.
“Other hospital obstetrical departments are afraid of providing care to pregnant women, and here we have a community hospital that stepped up to the plate and supports it. … In every way it stands out as a model for even big hospitals, such as Maine Medical Center, in how it’s possible to provide this level of care,” he said.
While many doctors are reluctant to prescribe medication for opiate addiction — leaving Maine with far too few physicians offering the drugs — Smith urges fellow practitioners to consider it.
He sees no reason why the treatment model that’s working in Bridgton couldn’t be replicated in many other Maine towns. Already, it’s being duplicated at a Bridgton internal medicine practice, and another family physician in nearby Fryeburg hopes to do the same, according to Bell.
“After people get treated, it’s really one of the best aspects of my practice, to see somebody come from that low point to being really functional and positive,” Smith said. “Their outlook on everything really changes.”
Kate graduated from Crossroads last month, but her fight to stay clean continues. After giving birth to a 6 pound 8 ounce baby boy on Jan. 7, she’s struggling to find an intensive outpatient program in her midcoast community that allows mothers to bring their newborns.
She’s patching together services made up of a weekly mother’s group, individual counseling and daily Alcoholics and Narcotics Anonymous meetings with her husband.
All of that is helping. But what doesn’t is shaming mothers with addiction, she said.
“Pointing fingers and blaming doesn’t help a lot,” Kate said. “We’re already judging ourselves way harder. I know that people don’t probably believe that, but it’s definitely true.”