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Newly Born, and Withdrawing From Painkillers

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The New York Times

April 9, 2011


Newly Born, and Withdrawing From Painkillers



BANGOR, Me. — The mother got the call in the middle of the night: her 3-day-old baby was going through opiate withdrawal in a hospital here and had to start taking methadone, a drug best known for treating heroin addiction, to ease his suffering.


The mother had abused prescription painkillers like OxyContin for the first 12 weeks of her pregnancy, buying them on the street in rural northern Maine, and then tried to quit cold turkey — a dangerous course, doctors say, that could have ended in miscarriage. The baby had seizures in utero as a result, and his mother, Tonya, turned to methadone treatment, with daily doses to keep her cravings and withdrawal symptoms at bay.


As prescription drug abuse ravages communities across the country, doctors are confronting an emerging challenge: newborns dependent on painkillers. While methadone may have saved Tonya’s pregnancy, her son, Matthew, needed to be painstakingly weaned from it.


Infants like him may cry excessively and have stiff limbs, tremors, diarrhea and other problems that make their first days of life excruciating. Many have to stay in the hospital for weeks while they are weaned off the drugs, taxing neonatal units and driving the cost of their medical care into the tens of thousands of dollars.


Like the cocaine-exposed babies of the 1980s, those born dependent on prescription opiates — narcotics that contain opium or its derivatives — are entering a world in which little is known about the long-term effects on their development. Few doctors are even willing to treat pregnant opiate addicts, and there is no universally accepted standard of care for their babies, partly because of the difficulty of conducting research on pregnant women and newborns.


Those who do treat pregnant addicts face a jarring ethical quandary: they must weigh whether the harm inflicted by exposing a fetus to powerful drugs, albeit under medical supervision, is justifiable.


“I’ve had pharmacies that have just called back and said: ‘This lady’s pregnant. Why do you want me to fill this scrip? I can’t do that,’ ” said Dr. Craig Smith, a family practitioner in Bridgton, Me. “But when you stop and think about what actually happens during withdrawal and how violent it can be, that would certainly be not in the baby’s best interest.”


Still, even doctors who advocate treating pregnant addicts have had moments of doubt.




There are no national figures that document the extent of the problem, but interviews with doctors, researchers, social workers and women who abused painkillers while pregnant suggest that it has grown rapidly, especially in rural regions, where officials say such abuse is most common.


In Maine, which has been especially plagued by prescription drug abuse, the number of newborns treated or watched for opiate withdrawal, known as neonatal abstinence syndrome, at the state’s two largest hospitals climbed to 276 in 2010 from about 70 in 2005. Hospitals in states including Florida and Ohio reported similar increases, and experts said the numbers were probably higher since pregnant women are rarely tested for drug use and many mothers do not admit to abusing opiates.




‘How Little We Know’


Rigorous studies on treating infant withdrawal are scarce, and the American Academy of Pediatrics has not published guidelines since 1998.


“It’s really remarkable how little we know about the effect of prescription drugs and even nonprescription drugs on the fetus,” said Dr. Nora D. Volkow, director of the National Institute for Drug Abuse. “There are real roadblocks in terms of helping us advance the field.”


Dr. Mark L. Hudak, a neonatologist in Jacksonville, Fla., is helping to revise the pediatrics academy’s guidelines. “There are commonalities, but it’s not like you can go to a Web site that says, ‘This is what should be used by everyone,’ ” Dr. Hudak said. “No one knows what the best approach is.”


Within states, every hospital that delivers babies exposed to painkillers may have its own approach. Eastern Maine treats affected newborns with tiny doses of methadone, while Maine Medical Center in Portland uses morphine combined with phenobarbital, a barbiturate that prevents seizures. Some hospitals are also experimenting with clonidine, a mild sedative that can relieve withdrawal symptoms.


There is growing debate over treatment for pregnant women addicted to prescription drugs, in light of concerns over the effects on their babies. Many are slowly weaned from their dependence with methadone, the standard of care for decades. Methadone, when taken in prescribed doses, keeps a steady amount of opiate in the body, preventing withdrawal and drug cravings that occur when levels dip. But it, too, can be addictive and cause nagging side effects like drowsiness. And for addiction treatment, it can be obtained only at federally licensed clinics where most users have to report for a daily dose.


A growing number of addicts are instead taking buprenorphine, another drug used to treat addiction that some studies suggest staves off drug cravings as effectively as methadone but is less likely to cause withdrawal in newborns. In rural areas of the nation, where methadone clinics are few, buprenorphine is considered a promising alternative because it can be prescribed by primary care doctors and taken at home.


But buprenorphine also appears not to work for some addicts.


Still, a study published in December in The New England Journal of Medicine showed that babies whose mothers had taken buprenorphine required significantly less medication after birth and less time in the hospital than did babies whose mothers were treated with methadone. But researchers cautioned that exposure to buprenorphine in utero can still cause withdrawal symptoms and that further study was needed.


“We don’t want it misconstrued that buprenorphine is a miracle drug,” said Hendrée E. Jones, a Johns Hopkins University researcher and the study’s lead author.


Even less is known about longer-term effects on babies exposed to painkillers, though in a second leg of their study, Dr. Jones and her fellow researchers plan to follow the 131 babies in the cohort until they turn 3.


A recent study by the Centers for Disease Control and Prevention found that babies exposed to opiates in utero, in this case legally prescribed painkillers, had slightly higher rates of birth defects, including congenital heart defects, glaucoma and spina bifida.


Experts say that since many drug users also smoke and abuse alcohol, not to mention that they face extenuating circumstances like poverty, it is difficult to tease out the effects of each substance on their offspring.


“Most of the literature suggests consistently that the drug exposure itself is not the primary concern,” said Karol Kaltenbach, a professor at Jefferson Medical College in Philadelphia who studies addiction in pregnant women. “It’s the cumulative effect of the drug-using lifestyle — poverty, chaos in the home, domestic violence. All those things affect development.”


Not all newborns exposed to opiates have severe enough withdrawal to need medicine; at Maine Medical Center since 2003, about 55 percent of babies exposed to buprenorphine and 80 percent of those exposed to methadone have needed treatment. But it is hard to predict which ones will need it: a newborn whose mother was on a high dose of either drug might need none, while a baby whose mother took a low dose might experience acute withdrawal.


Babies known to have been exposed to drugs are often kept in the hospital for at least five days because withdrawal symptoms usually do not set in immediately. Nurses examine them for a checklist of symptoms every few hours, assigning each baby a score that, if high enough, calls for treatment.


“They don’t stop crying, they can’t settle down, they don’t relax,” said Geraldine Tamborelli, nursing director of the birthing unit at Maine Medical Center, which in 2010 diagnosed opiate withdrawal in 121 newborns. “They’re struggling in your arms instead of snuggling into you like a baby that is totally fine.”


In the neonatal intensive care unit at Eastern Maine, Kendra, 3 days old, was sleeping in a dark, silent room one morning, away from the bustle and bright lights that can be especially irritating to babies going through withdrawal. Nurses frequently crept in to observe her, though, and by the afternoon her limbs had stiffened and she was crying excessively and having tremors; it was enough to begin treatment.




On the pediatric ward, Matthew started fussing while his mother, Tonya, talked to reporters that afternoon in January; his cry had a strange, reedy pitch that nurses say is common to babies with his condition. The small dose of methadone he had received gave him gas and heartburn, for which he was given two stomach medications. He also was on clonazepam, a muscle relaxant and anti-anxiety drug that helped him metabolize the methadone more slowly.


Tonya said that at first she “didn’t believe in” methadone treatment during pregnancy and that doctors had to persuade her that it would not hurt her fetus. She had experienced wrenching withdrawal when she stopped using painkillers after learning she was pregnant, she said, and the doctors had warned her that “when I was feeling that bad, he was feeling 1,000 times worse.”


Tonya said that in a previous pregnancy, she quit using drugs altogether and miscarried a month later.


“That was the last thing I wanted to happen this time,” she said.


Avoiding Addicts, and Liability


Treating drug-dependent mothers and babies is often lonely work, with little communication among the doctors who take it on. As Dr. Brown said, “My network for people who do this is really very small.”


Dr. Mark R. Publicker, an addiction medicine specialist at Mercy Recovery Center in Westbrook, Me., is on a mission to get more of the state’s doctors to treat pregnant prescription drug abusers and more hospitals to deliver their babies. Only a handful of doctors here treat pregnant women with buprenorphine, Dr. Publicker said, partly because they fear liability and do not want to deal with addicts.


The fact that most hospitals will not deliver the babies makes doctors even less likely to treat the women.


“It’s mostly ignorance,” Dr. Publicker said. “It’s a concern that it’s a risky proposition and that they’re going to wind up with an ill baby.”


In February, Dr. Smith persuaded Bridgton Hospital, which has only 25 beds, to deliver the babies of women on buprenorphine — a major victory, he said, because until then women in rural southwestern Maine had to drive an hour or more to Maine Medical to deliver.




“I’m proud that I changed my life,” Tonya said. “But at the same time, when you see your child in pain and you know your child is in pain because of a life decision you made, it’s the hardest thing in the world.”

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Cinephile was just talking with Robert Whitaker about the conundrum of continuing prescribing Class D Paxil to a pregnant woman -- damage to fetus from drugs v. damage to fetus from w/d and risk of suicide or severe illness of woman. Whitaker said one in six pregnant American women is taking an SSRI?!


And talk about dysautonomia. The children exposed to crack in utero have to deal with akathisia and tremendous difficulty regulating themselves.


It's really overwhelming. I'm grateful to the health professionals who want to take on these desperate situations.


All we can do is keep doing our bit to spread the word and help people turn these negative situations into something positive. As I just said to Claudius, it's an evolutionary process for us as a species!!! :(

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Cinephile was just talking with Robert Whitaker about the conundrum of continuing prescribing Class D Paxil to a pregnant woman -- damage to fetus from drugs v. damage to fetus from w/d and risk of suicide or severe illness of woman. Whitaker said one in six pregnant American women is taking an SSRI?!...


In a rational world, prescribing antidepressants to a pregnant woman would be an unacceptable risk. The suicide rate in the US is .0113 percent and women are at even lower risk (11.3 suicide deaths per 100,000 people, almost four times as many males as females die by suicide, see http://www.mentalhealth.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml)


Depression in a pregnant woman could be treated by non-drug means to lower the risk to the fetus and newborn. The cause of most post partum depression is probably social isolation (see http://www.ncbi.nlm.nih.gov/pubmed/11028570), which could be treated by putting the woman in group therapy, a new mothers support group, or other social situation -- much healthier for both mother and child in the long run.


What also struck me about this article was how similar the newborn's symptoms are to neonatal antidepressant withdrawal.

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Those are really good ideas for psycho-social support, Sur.


If we're talking about pregnant women who are not already on a med, I'm completely against taking any such risk to the fetus. I've already talked one pregnant woman out of starting a Class C antidepressant in the strongest possible terms, after her OB/Gyn *pushed* them on her, just like a drug pusher -- "They'll make you feel better. And that's good for the baby."


But, if we're talking about pregnant women who are already dependent on these meds, I feel there's a lot I still don't know. For instance, do we really know that it is preferable to wean a fetus off meds than to have a neonate dependent on them? If a pregnant woman stops taking the meds early in pregnancy, what does the fetus go through? How does that affect fetal development? Is the neonate really finished with w/d after, say 2 months of exposure in utero, followed by 7 months in utero without the drug? Maybe the best protocol will turn out to be -- stay on the meds, breast feed, taper super-slowly. Lots of unknowns still, alas.

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