The birth of a crisis
In midst of heroin epidemic, hospitals struggle with newborn addicts
The newborns are fussy. They can’t get to sleep, can’t eat and certainly can’t be comforted. When they do eat, they may have horrible diarrhea that can result in dehydration or severe cases of diaper rash. They might clench their muscles or get jittery. They can’t regulate their emotions, so a relatively minor problem could lead to a major meltdown.
They are the youngest victims — the involuntary casualties — of an epidemic. Dozens to hundreds of infants each year are born addicted to opioids.
“The crisis is huge right now,” said Susanna Prensner, a licensed clinical social worker who specializes in pediatrics.
She should know. Prensner works with newborns in the Neonatal Intensive Care Unit (NICU) at St. Francis Medical Center, and she said it is rare that the hospital doesn’t have at least two infants going through the painful process of withdrawal.
The numbers support her assertion. In a two-month period last summer, the NICU cared for 19 babies born with neonatal abstinence syndrome (NAS), the technical term for infants exposed to addictive drugs while still in the womb. That accounted for about 17 percent of the 109 total NICU newborns treated during that same time frame.
Of those 19 addicted newborns, only nine came from El Paso County. The remainder came from communities lacking such specialized medical care, such as the comparatively rural Alamosa.
Prensner is quick to point out that this period represented an unusual spike in services and needs to be viewed as a point-in-time sample, rather than a blanket measure of the issue. And, to be honest, that’s part of the problem.
While hospitals anecdotally track their cases of addicted babies, there is no statewide or federal database or other mechanism to keep tabs on the numbers.
WHAT’S THE DIFFERENCE?
The terms “opioids” and “heroin” are often used interchangeably, but strictly speaking, they are not one and the same. Opioids are a class of highly addictive drugs that interact with receptors on the nerve cells to block pain. They include prescription painkillers such as oxycodone, hydrocodone, codeine and morphine; synthetics such as the powerful prescription fentanyl; and illegal street drugs such as heroin itself.
Related content: Your two cents: Shed the word to shred stigma
There is, however, a statewide Birth Defects Registry maintained by the Colorado Department of Public Health and Environment. Margaret Ruttenber, a department research scientist and program director for Colorado Responds to Children with Special Needs, manages the registry.
There are about 1,300 conditions that the registry tracks, she said. That includes cases of neonatal abstinence syndrome. Between 2010 and 2017, 1,719 such cases were reported. The largest spike of 290 reported cases came in 2016, compared to the lowest number — 128 — in 2010.
But those statistics have limitations.
Only some hospitals — members of the Colorado Hospital Association — provide data, as reporting is done on a voluntary basis. This means that not every NAS birth in the state is included in the Birth Defects Registry. The reports also use specific codes, so statistics don’t specify what drug the mom was using when the babies were born, Ruttenber said.
So there is no way to know whether the baby came into this world dependent on opioids, methamphetamines, cocaine or something else.
“It hasn’t been written into the hospital association [guidelines]… yet to break down to that level,” Ruttenber said. “When this gets reported, in order to really know, you would have to go back into the medical record.”
Which brings even more complications.
For one thing, medical records are protected under federal privacy guidelines. For another, it is an incredibly pricey and time-consuming proposition to send researchers across the state to dig into and process the data. And the federal Centers for Disease Control and Prevention, which would be the organization to fund such research, has no immediate plans to undertake an active study of fetal opioid dependency.
But that sort of active study is exactly what’s needed to get a complete picture of the problem. The government used that model, Ruttenber said, to get a better understanding of fetal alcohol syndrome nearly two decades ago.
“The CDC gave us money and we could actively go out and ascertain,” she said. “We went to clinics, we went to hospitals.
“It’s very costly to go out and look for medical records.”Evidence of growth
In essence, the state’s hands are tied by bureaucratic regulations and no funding, despite the fact that state public health data show that in 2015, there were at least 160 fatal heroin-related overdoses. In 2006, there were only 39 fatal overdoses. Further exacerbating the crisis, the National Institute on Drug Abuse reports that in 2015, a whopping 64.7 prescriptions were written for highly addictive opioids for every 100 Coloradans.
That same year, the Rocky Mountain High Intensity Drug Trafficking Areas sponsored a multi-jurisdictional meeting with state and federal health and law enforcement agencies to tackle Colorado’s heroin problem. From this, the Heroin Response Work Group was born.
The agency releases an annual report on opioid use in the Centennial State, and the 2018 review — the most recent available — shows that between 2011 and 2016, the rate of NAS grew from 2.6 per 1,000 live births (0.26 percent) to 4.4 per 1,000 (0.44 percent). The numbers came from Ruttenber’s registry, and while the increase may not sound like much, it represents a 69 percent increase in just five years.
But mathematically speaking, at Pueblo’s Parkview Medical Center, in 2015 the number of addicted infants was nearly 10 times that reported rate.
“In 2012, 2015 and 2017, we were right around 20 (addicted infants) per 1,000 (births),” said Camille Hodapp, a neonatal nurse practitioner who helps run the special care nursery there. “It was all over the nation around that time.
“It took a lot of time to really believe that was happening and then it just hit us. It increased so rapidly.”
All that comes with some hefty costs, too. According to a study published in the April 2018 edition of the journal Pediatrics, Medicaid covered care related to some 82 percent of the nation’s NAS-related births in 2014 at a cost of $462 million.
That’s the price tag, but the social cost of children born dependent on highly addictive substances has yet to be seen.
“I can’t answer that question honestly, because this is something that has more recently happened,” Hodapp said. “We’re going to need to do some research and long-term follow-up. That’s really hard to do with this population in general: Keeping them in contact for 20-plus years to see, now, did this child start using heroin later on in life?”Peak and ebb?
Dr. Pastora Garcia-Jones is a neonatologist at UCHealth’s Memorial Hospital who also works with NAS babies at Parkview. She is also a member of the Colorado Hospital Substance Exposed Newborns (CHoSEN) collaborative, a 17-hospital-strong coalition of caregivers dedicated to getting to the heart of the crisis and promoting the best practices for treating drug-dependent newborns.
The collaborative, she said, is gathering the type of information that the state can’t. Specifically: What drugs a mother-to-be used while pregnant, when a newborn’s withdrawal started, how the infant was treated and general details on the baby’s recovery.
“What we’re collecting at CHoSEN … is clinical data,” Garcia-Jones said. “The health department collects data on low birth weights, stillbirths. But as far as data we’re doing something with, as far as I know the CHoSEN collaborative is the first of its kind.”
She said the neonatal abstinence wave peaked at different times in different cities, as the use of heroin spread across the state. The crest in Pueblo came ahead of that in Colorado Springs, she said, but that doesn’t mean the tide is necessarily turning.
She cited the widespread use of prescription opioids leading to an influx of dependent women as driving the trend. But as the understanding and media coverage of the epidemic have grown, doctors are putting down the prescription pads, meaning cases of opioid-involved NAS could taper off.
“It peaked and it slowed down,” Garcia-Jones said. “It’s still way higher than it was in 2006, right, but we’re talking three to five times more babies than we used to have.”
“If you can get the mother to bond with the baby because she is part of the solution rather than the problem, that has been shown to reduce recidivism.” — Dr. Pastora Garcia-Jones
Treating an infant as it battles its way through withdrawal is no easy task. It doesn’t automatically start detoxing the minute it emerges from the womb. Depending on when its mother last used, the baby might seem healthy for several hours. Across the region, laboring women are verbally screened regarding their drug use. If hospital staff has reason to believe the mothers aren’t being 100 percent honest, a urine test can provide concrete results.
When an infant’s symptoms — fussiness, high-pitched crying, jitteriness, poor appetite and an overall failure to thrive — start, they come on strong.
“You start to see (the symptoms) within 24 to 48 hours, usually,” Parkview’s Hodapp said.
Her unit subscribes to what’s called the “eat, sleep, console” method of treatment. Babies are kept in a quiet, calm and dim environment, swaddled and allowed to suck on a pacifier.
“Having them be held a lot actually keeps them comforted through the withdrawal process,” Hodapp said.
Those who can sleep between feedings and be soothed before fussiness turns into a meltdown are kept off medicines and allowed to detox naturally. It’s a holistic approach that encourages family participation in the process.
That method has positive benefits for the parents, too, Garcia-Jones said. That’s because, she believes, every mother wants to do the right thing for her baby.
“The most important linchpin to all of this is getting the parent involved,” she said. “That is really good because it gets the babies home, but the benefits go well beyond the hospital. If you can get the mother to bond with the baby because she is part of the solution rather than the problem, that has been shown to reduce recidivism.
“Positive reinforcement works.”Mothers’ needs
But how far can the “eat, sleep, console” method go to truly helping a fractured family to heal?
St. Francis’ Prensner and fellow pediatric social worker Jeanne Moore aren’t entirely sure. Their hospital is working to implement the model; but for the time being it still utilizes a tiered treatment plan that involves medicating opioid-addicted infants with morphine and clonidine, and slowly stepping them off of the meds.
“A baby like that could stay for two months, depending on a lot of other factors,” Moore said.
During that time, the hospital and its social workers have plenty of opportunity to interact with the parents. Because they are mandatory reporters in cases of suspected child abuse, care providers are obligated to contact county social services when a mother reports drug use. The exception comes when the drug in question is used to help treat opioid addiction and shows the mother is attempting to get sober, Moore and Prensner said.
And that is at the heart of a medical paradox.
Hospitals are obligated to care for their patients, regardless of socioeconomic status — as long as those patients aren’t using illegal drugs. But if a mother who is also going through withdrawal is caught getting high on hospital property, she must leave the premises and her baby behind.
At the same time, physicians with the prescriptive power to medically treat those mothers may shy away from doing so, the social workers said. Treating addiction with a potentially addictive drug may feel counter-intuitive. Prensner believes training doctors about the benefits of medication-assisted treatment could help ease the stigma.
Further complicating the problem is the fact that in-patient recovery programs are slim in Colorado. Factor in a pregnancy or a new delivery, Prensner said, and they become nearly non-existent.
She and Moore work closely with the families, with the social services of their home counties and with the medical team to connect parents with the resources they need to recover, and to find the best possible home for each baby.
“It’s our mission to help people heal and grow,” Prensner said.
“This is not going away,” Moore added of the crisis. “This is only going to get worse.”