Augusta University Health
It started innocently enough with a little pain.
Maybe you had to have surgery or were in an accident. Or maybe it was that athletic injury that just wouldn’t heal, or it was an overuse injury related to your job.
But suddenly the pain pills are the most important thing in your life. You can’t go more than a few hours without one. And you’re hiding how important they really are—from your spouse or significant other, your family, your friends.
Then you become pregnant.
Experts began talking about an opioid epidemic more than two decades ago. And women—particularly those of childbearing age—are in the age range at highest risk for addiction. “It’s estimated that the percentage of women who are pregnant and addicted to opioids is as high as 10 percent,” said Dr. Paul Browne, a maternal-fetal medicine specialist at Augusta University Health. Other studies in certain communities have even found rates as high as 29 percent.
But, when women become pregnant, their unborn baby often becomes more important than the medication. Many want to withdraw. The catch-22 is that drug rehabilitation is a time when addicts are at highest risk for relapsing and overdosing—and potentially dying.
Difficult Choices
It may be hard to believe, but the old thinking has been for women who are pregnant and addicted to opioids not to attempt rehab. Some evidence has found that withdrawal can increase the chance of miscarriage and stillbirth. Another reason for not withdrawing is that increased risk of death by overdose.
But the result is that babies are born, like their mothers, addicted to opioids. Watching a baby undergo withdrawal in an ICU, with vomiting, seizures, shaking and screaming—it’s something no parent wants to ever experience.
The tide, however, is turning. The case against detoxification during pregnancy stems from two cases dating from the 1970s, and researchers have since examined many others beginning in the 1990s that found that withdrawal actually doesn’t pose an increased risk of miscarriage and stillbirth.
Other challenges remain. Many treatment programs don’t accept Medicaid—and 60 percent of pregnant women in Georgia are Medicaid patients. Also, the United States Drug Enforcement Administration continues to discourage withdrawing patients during pregnancy, so licensed narcotic treatment programs are at risk for losing licensure if they do so. Still, women who are pregnant and want to withdraw have several options in Augusta, said Browne.
For example, Augusta University Health offers an in-hospital medically supervised withdrawal over the course of four to 10 days where patients quit opioids immediately and are provided with supportive medications to manage symptoms, such as nausea, rapid heartbeat and diarrhea.
In addition, Browne began an outpatient medical supervised withdrawal clinic at Augusta University Health in 2012. The model is unique: Each patient must have a care partner, usually a family member or significant other, who agrees to dispense narcotics to the addict in decreasing amounts over the course of pregnancy. “We carefully explain that role, and we are also very frank with the patient and the care partner about relapse and the chance of death,” said Browne.
Narcotics are required to be locked away and only the care partner has access. Browne counsels patients to expect some withdrawal symptoms as levels are decreased, and like the inpatient program, medications to manage withdrawal symptoms are provided.
“The goal is to steadily decrease narcotic use over six to seven months and for the patient to fully withdraw about two to four weeks prior to the due date,” said Browne. “We have found that getting off narcotics close to the due date provides greater motivations for the mother and reduces risk of relapse.”
The clinic has treated close to 100 women since opening five years ago. And it has found that for patients who successfully complete the program, 100 percent of their babies avoid neonatal abstinence syndrome (NAS)—or in other words, have no need to undergo withdrawal. This is compared to a 40 percent risk of NAS for patients who decide not to withdraw and remain on narcotics like methadone or suboxone. Patients who attempt to withdraw and relapse have the worst outcomes.
“What we’ve seen is that there are generations of people who experience substance abuse,” said Browne. “There’s a realization that people are born with this predisposition. So there is compassion there too. For women seeking help, who are motivated by their pregnancy, we’ll help you.”
Lindsey Morris
Chris Curry