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The number of babies born exposed to opioids is down at one of Maine’s largest hospitals, which might appear to be a positive sign. But the decrease is more puzzling than anything, according to health professionals around the state.
Over the last four years, the number of babies born at Northern Light Eastern Maine Medical Center in Bangor to mothers taking some type of opioid has decreased by 35 percent. In 2015, there were 202 opioid-exposed babies, and in 2018 there were 131, said Dr. Mark Brown, a neonatologist and chief of pediatrics. Meanwhile, the state’s largest hospital in Portland has seen its number of opioid-exposed infants remain steady.
Curious what was happening, Brown dug deeper into the numbers and learned that the number of babies born to mothers taking illicit opioids, such as heroin, had stayed the same. Rather, the decline has been driven by fewer babies each year being born to mothers in methadone treatment. If fewer women are getting help for their substance use disorder, or many are fatally overdosing, the decrease in opioid-exposed babies may actually be a cause for concern, Brown said.
The umbrella term of “opioids” encompasses more than illicit drugs such as heroin. It also includes medications used to treat opioid addiction, such as methadone and buprenorphine, which reduce cravings and don’t produce a high when taken as prescribed. It is safer for pregnant women to stay in treatment, rather than continue to use illicit substances or go off narcotics entirely, which can cause miscarriage.
The discussions that have ensued around the decline show just how much there is still to learn.
Are more women with a substance use disorder accessing birth control and not getting pregnant? Is a shift underway in the type of addiction treatment women are willing or better able to pursue? Are women avoiding medical treatment during their pregnancies? Have their deaths cut short the number of babies who otherwise would have been born? Or have more women simply chosen not to have a baby?
Over the past four years, the number of infants born at Northern Light Eastern Maine Medical Center to mothers taking methadone as part of a treatment program declined 37 percent, Brown said.
The hospital declined to release hard numbers to protect patients’ privacy, but Brown said the decline has been steady and significant. The wellbeing of babies is often considered a bellwether for a place’s overall health, so what happens to Maine’s population of substance-exposed babies will be important to watch.
The hospital saw a 5 percent increase in the number of babies born to mothers taking prescribed buprenorphine. But that slight increase did not make up for the drop in mothers taking methadone, Brown said, suggesting it’s unlikely that pregnant women are simply switching to a different treatment medication.
The hospital also saw a decrease in infants exposed to prescribed narcotics for their mothers’ pain, but that subset of babies has historically been small.
Brown said he does not know what is causing the decline in pregnant women taking methadone, but it’s not likely that fewer women are addicted to opioids. Federal surveys show those rates remaining steady.
“I don’t know where those mothers went,” Brown said. “You don’t know what you’re not seeing. It’s hard to know. But I worry.”
That was also the initial reaction of Dr. Alan Picarillo, a neonatologist at the Barbara Bush Children’s Hospital at Maine Medical Center in Portland. “I’d be worried about access [to treatment]. That’s typically what it is — access to providers,” he said.
Methadone clinic Penobscot County Metro Treatment Center in Bangor did not return a request for comment.
Another potential theory for the decline is that more women with opioid use disorder are receiving buprenorphine at primary care offices, where they are also getting birth control and having fewer babies, Brown speculated. (Methadone clinics don’t focus on reproductive health.) The area certainly has seen a marked increase in access to buprenorphine.
In addition, Penobscot County, like Maine as a whole and even Cumberland County, has seen a slow decline in the overall number of births.
But it’s not clear that access to birth control in the Bangor region has actually improved.
Dr. Noah Nesin, vice president of medical affairs at Penobscot Community Health Care, said the organization does not have data on the number of women with opiate use disorder who have birth control, but there is no indication that there’s been a dramatic increase. In fact, some women still struggle to access the most effective forms of contraception — implants or intrauterine devices — because of transportation or cost barriers, he said.
A far more worrying theory is that so many women of child-bearing age have died, such as by overdose, that it’s cut short the number of babies who would have been born.
“I’d hate to think it’s a phenomenon like that affecting women of child-bearing age in this state,” Nesin said.
Women have been hit hard by the opioid crisis. Between 1999 and 2015, the rate of deaths from prescription opioid overdoses increased 471 percent among women in the United States, compared with an increase of 218 percent among men, according to the federal Office on Women’s Health. Heroin deaths among women increased at more than twice the rate of the increase among men.
In addition, between 2012 and 2017, the number of women in Maine who died of opioid overdoses tripled, increasing to 90 up from 32, according to the Kaiser Family Foundation. And there was a recent spike in drug- and alcohol-induced deaths among women in Penobscot County. (Men still make up the bulk of people who die from drugs.)
But Dr. Marcella Sorg, who compiles drug overdose trends for the Maine attorney general’s office, said she has not noticed an increase in overdoses among women of childbearing age.
It appears that there has, however, been a decrease in pregnant women, primarily without insurance, who are in treatment for substance use disorder, according to the Maine Department of Health and Human Services.
In southern Maine, fewer pregnant women have also been choosing methadone, but they switched to buprenorphine instead. “Over the years our methadone numbers have gone down, and they’ve been replaced by buprenorphine,” said Picarillo, with Maine Medical Center in Portland.
Today, about 85 to 90 percent of opioid-exposed newborns born at the state’s largest hospital are to mothers in treatment, he said. For each woman on methadone, there are about three on buprenorphine.
While newborns can experience withdrawal — including tremors, twitching and persistent crying — when their mothers take methadone or buprenorphine, the symptoms are usually milder than with street drugs.
Unlike at Northern Light Eastern Maine Medical Center, it appears the number of opioid-exposed newborns born at Maine Medical Center has remained steady. It had 100 opioid-exposed babies in 2016, 122 in 2017 and 201 in 2018, Picarillo said. In the first quarter of 2019, it had 21.
Mark Moran, the family support services coordinator and a licensed clinical social worker at the Bangor hospital, said the neonatal intensive care unit is still busy, even if there’s been a decline in opiate-exposed babies.
“These families are complex enough in many cases,” he said. “I’m not sure if we’ve consciously felt a big difference in terms of workload or in terms of the nature of the patients.” When it comes to the decline in babies born to mothers taking methadone, “It’s too soon to tell [the reason], and there are too many complicating factors to clearly answer that question,” he said.
Maine Focus is a journalism and community engagement initiative at the Bangor Daily News. Questions? Write to firstname.lastname@example.org.