Appalachian Clinics Shaping How Best to Treat Pregnant Women who are Addicted to Opioids

A young mom – we’ll call her Patient A – is sitting on a couch holding her infant son at Karen’s Place, the newest in-patient treatment program for pregnant women in Louisa, Kentucky.

She smiles down at the healthy infant in her arms, then begins to talk about her older son – now 2½.

“He was actually born addicted,” she said.

“I could not, I could not quit when I was pregnant with him, as much as I wanted to, as much my mind told me every single day that I could,” she said.

“I was just under the grips of this disease, and there was no way I could. And he had to stay in the hospital for almost three months. He’s happy and healthy now.”

If someone addicted to opioids wants to overcome that addiction, there are generally two approaches to initial treatment: (1) medically supervised “cold-turkey,” so to speak; (2) or medication-assisted tapering. The latter involves getting the patient off their drug of choice and into a methadone or Suboxone program, which allows them to avoid the worst of the withdrawal symptoms while their dose is lessened over time.

But things get a little tricky when it’s a pregnant woman who is seeking treatment.

Detoxing While Pregnant

“When patients undergo detoxification or complete withdrawal – even just a supervised withdrawal ­– the risk, probably the greatest risk, the most common risk, is that of relapse,” said Maria Mascola, a nationally recognized high-risk obstetrician based in Wisconsin. And relapse carries a higher risk of overdose.

“The balance of the evidence strongly supports the opioid-assisted treatment during pregnancy for the stability it offers,” Mascola said.

But if a woman participates in an opioid replacement therapy program while pregnant, even though she isn’t “using” illegally anymore, her baby will likely be born with symptoms of Neonatal Abstinence Syndrome. This means the babies will go through withdrawal.

And “we know it is better for babies to be born drug free,” according to Kim Miller – director of corporate development for Prestera Center in Huntington. Prestera runs both an in-patient and out-patient treatment program for addicted mothers and pregnant women.

“So even if a pregnant mom was addicted to drugs and had the disease of addiction earlier on in the pregnancy, if she can deliver a drug-free baby, she saves the baby from medical interventions,” Miller said. “She saves herself and she saves society – it’s expensive to put babies in neonatal intensive care units, especially for a problem that is preventable.”

The national average hospital charge for a baby being treated for Neonatal Abstinence Syndrome is about $93,000, according to the Centers for Disease Control and Prevention. The average cost of a woman going through Prestera’s in-patient treatment program? About $14,600 for an average stay of about 6 months.  

But getting women off drugs before the birth of their child isn’t always easy – or advisable.

Cabell-Huntington Hospital

David Chaffin is a high-risk obstetrician in Huntington who runs a maternal addiction recovery center.

Chaffin said for women “appropriately” willing and ready – that is, highly self-motivated – tapering doses can allow a mother to be off drugs completely by the time her child is born.

“This is not a in-patient 72-hour detox program,” he said. “That stress – that is, just going cold turkey – problem does carry some fetal risk, but the slower detoxification programs are safe to use.”

He emphasized that in his opinion, requiring detox through a court order or obstetrician encouragement is dangerous, because if the mom isn’t invested in her own recovery, the risk of relapse is really high.

“If 70 percent are relapsing, that means rather than being in a stable program they are using drugs off the street, with all the attendant infection risks, the attendant risk of overdose,” he said.

Appalachia has been hit hard by the opioid crisis. At Cabell-Huntington Hospital where Chaffin works, 140 out of 1,000 births are babies with Neonatal Abstinence Syndrome. Nationwide the number is about 6 per 1,000 births.

So centers are coming up with a variety of ways to treat these patients. One doing things a little bit differently is Crosswinds outside Lewisburg.

Crosswinds

“Mostly in the first trimester we’re looking to detox completely off…with detox we’re going to zero,” Crosswinds medical director Dr. Noel Jewell said. “So when they leave, they’re not on any other medications other than prenatal vitamins or any other medications their OB would like them on.”

Jewell does use buprenorphine to ease the symptoms of withdrawal. But unlike Chaffin’s center, where a detox tapering can take 10 to 12 weeks, Jewell’s center does it in 5 to 7 days. Then the patients are monitored for a minimum of 72 hours (with an average total stay of 10 to 15 days) and released back to the care of an obstetrician.

“I will admit that our first priority is trying to have a baby delivered without Neonatal Abstinence Syndrome…but after that, they’re scattered across the state. We’re trying to collect some data now to see if they followed up with someone. Did they go back on methadone or Suboxone?”

As far as Jewell can determine, his center has been successful in reducing the number of addicted newborns – at least on the local level, where his group has strong OB-GYN support.

However, he said relapse is definitely a concern. Detox is only the first part, then ideally comes counseling, but this isn’t always readily available.

In 2012, the American College of Obstetricians and Gynecologists (ACOG) came out with a committee opinion on opioid abuse, dependence and addiction in pregnancy. Their conclusion? Opioid maintenance therapy is the best practice.

Jewell acknowledges that Crosswinds treatment protocols differ from what ACOG recommends. But, he said, there isn’t a lot of definite data one way or another. For one thing, some of the studies ACOG referenced in their 2012 recommendations lack currency, dating back to the 1980s.

Maria Mascola – the obstetrician in Wisconsin – is part of the current ACOG committee reviewing the 2012 guidelines to see if they need to be updated. For her, opioid replacement therapy for the entirety of the pregnancy is still the best practice. But she added that she hopes practitioners of alternative approaches, like Chaffin and Jewell, will publish their findings. Because this problem isn’t going away anytime soon, and more research and data help everyone determine what works well and what doesn’t.  

Editor’s note: This story and its headline have been updated to include more accurate language and characterization of pregnant mothers who are in treatment for drug addiction.

Appalachia Health News is a project of West Virginia Public Broadcasting, with support from the Benedum Foundation, Charleston Area Medical Center and WVU Medicine.