Nothing can prepare a mother for seeing her newborn seize multiple times an hour, refuse to eat or sleep, and shake uncontrollably. That’s what Julia found herself facing after severe chronic back pain from a car accident left her dependent on opioids. Julia had been a college student from a middle class family with a bright future and never imagined she would end up an addict with a newborn diagnosed with Neonatal Abstinence Syndrome (NAS).
Julia’s story mirrors that of hundreds of thousands of Americans who are prescribed pain killers like Vicodin or OxyContin to heal from an accident, surgery, or cancer, and find themselves addicted and unable to stop – even when pregnant.
Her newborn child is one of more than 27,000 born annually addicted to opioids—one born every 25 minutes. Instead of being placed in a mother’s arms, babies like Julia’s are rushed to the Neonatal Intensive Care Unit (NICU) where they stay for weeks at a time. Their very first sensation in life is feeling “dope sick” – the painful detox that opioid addicts will often do anything to avoid.
This preventable condition is caused by exposure to prescription pain medications or heroin while in the womb. And it is a condition that doesn’t discriminate. The opioid epidemic has touched everyone from the upper-middle class lawyer who needed pain killers following a skiing accident to the unemployed single mother who shoplifts to pay for her intravenous drug habit.
NAS is one of the fastest growing newborn conditions in the U.S., quadrupling nationally from 1.5 per 1,000 hospital births in 1999 to 6.0 in 2013. In hard hit states such as Vermont, West Virginia, and Maine, children are twice as likely to be born with NAS than Autism, with NAS rates of more than 30 per 1,000 births. These newborns suffer from seizures, fever, diarrhea, vomiting, low birth weight, and other complications.
While we don’t yet know all the long term consequences of NAS, it can include lifelong cognitive and psychological trauma, developmental delays, learning disabilities, and heightened susceptibility to addiction. And the costs to the health care system are astronomical. The medical expenditures for a NAS baby are about $66,700 with an average hospitalization of nearly 17 days, compared to $3,500 and a two-day hospital stay for the average healthy baby. Taxpayer-funded state Medicaid agencies are struggling to keep up, having to shoulder approximately 80 percent of the costs. NAS also carries heavy societal costs, requiring increased expenditures on social services, special education, and sadly, the criminal justice system. These children are born at a social, mental, and physical disadvantage as a result of a condition that is 100% preventable.
Steps must be taken to curb over-prescription of opioids. Last year, enough opioid prescriptions were written to give nine out of 10 American adults their own bottle of pain killers. Our country is suffering from what the National Institutes of Health is calling “an urgent public health problem,” with opioid-related deaths quadrupling between 1999 and 2014—outpacing deaths from automobile accidents. Some changes are underway, like encouraging physicians to write prescriptions with fewer doses. But as these take hold, it’s imperative to take action now to protect the innocent unborn children who are at risk.
To begin, we must consider why the health care system is failing to meet the needs of these expectant mothers. There’s no single answer to this question. It’s a combination of factors, including a nationwide shortage of substance abuse treatment professionals, which often means treatment facilities and outpatient programs can only operate at partial capacity; cost barriers to treatment including limited insurance reimbursement; inadequate mental health services and coverage; and disjointed care that fails to address the determinants of addiction.
There also remains a stigma attached to addiction. Some can’t understand why a pregnant woman wouldn’t simply stop taking a substance that could harm her newborn child. But as ABC anchor Elizabeth Vargas poignantly explained about her own battle with addiction, “I would not hesitate for a nanosecond to step in front of a bullet, to do anything to give my life for my children. I would kill for my children. And I [still] couldn’t stop drinking for my children.” It’s not about love or choice or strength—it’s a disease.
To better serve these mothers who struggle with the disease of addiction, new opportunities are opening up with recent evidence-based care and treatment recommendations.
There has been a longstanding debate in the medical community on how to address opiate addiction during pregnancy, with fear that detoxing the mother could result in premature labor or fetal death. In March 2016, a groundbreaking new study was released which demonstrated that a woman can safely detox during pregnancy, and—with the proper ongoing care and support—can prevent NAS in her baby. The five-year study of 301 opiate-addicted pregnant women found that detox reduced the incidence of NAS births, and was most successful when paired with follow-up behavioral therapy to prevent relapse. Those in the study who benefited from some level of treatment following detox had much lower relapse rates and a greater likelihood of breaking their opioid dependence. This translated into fewer babies born with NAS.
This study not only demonstrates the importance of weaning a pregnant mother off opioids, it also highlights the key role of aftercare to keep her off drugs. Care coordination—which is increasingly compensated for under certain value-based payment models—will be vital to making sure those who want help get the services they need and don’t fall through the cracks. A mother will leave a detox center or the emergency department either unaware of the support options available to her, or overwhelmed by the challenge of navigating the healthcare labyrinth. Physicians, behavioral health specialists, counselors, and peer recovery programs all have a role to play in an improved team-based approach. Too often in a community, existing care services are disconnected, not comprehensive, and lack the resources to maximize patient engagement. New models, including delivery of care in alternative settings such as in the home and via telemedicine, must be incorporated.
To effectively implement team-based care in many parts of the country will require an increase in substance abuse and mental health professionals, as well as more treatment facilities that can serve pregnant women and families. According to the U.S. Substance Abuse and Mental Health Services Administration, fewer than 2,000 of the 11,000 listed treatment facilities include services for pregnant women, and even fewer provide accommodations for women with children.
Finally, we must convince states, insurers, and providers of the importance of making a front-end investment to tackle opioid addiction. According to the National Institute of Drug Abuse, “every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1.”
The financial savings would expand further when the health and lifelong well-being of a child is factored in. Nationwide, NAS cost $1.5 billion in health care expenditures in 2012 alone. In my home state of Tennessee, where we are number two in the nation for opioid prescriptions written, NAS cost our state Medicaid agency nearly $46 million in 2012, accounting for 13 percent of all money spent on live births. Some estimates now put that taxpayer cost at $60 million. Investing the funds to identify, support, and treat at-risk expectant mothers will lead to decades of long-term savings across the spectrum of health and social services.
We must look at healing these women differently, and in the process, change the long-term health outcomes for thousands of children. Through focused attention, a team-based approach to care, and application of modern evidence-based treatment, we can reverse the devastating trends of NAS so that the birth of a child can be a time of joy and not an experience marred by addiction.
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.