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Advocates with the Community Care Plan of Eastern Carolina help marginalized pregnant women and their babies get proper attention.
By Taylor Sisk
Detox won’t be easy for Courtney Moore’s daughter, a child who’s yet to enter the world.
The plan is that on Nov. 21, Moore’s baby will be delivered by C-section. The child will then begin withdrawal from buprenorphine, a drug that, like methadone, is used for the treatment of opioid dependence. She’ll likely be jittery and cry even louder and longer than the average newborn.
Her skin may blotch. Her muscles may tense.
She’ll be swaddled and calmed, of course, and very closely monitored. She may begin to have seizures. She might require morphine – initially just a drop on the tongue, by IV if deemed necessary. She’ll gradually be weaned as the opioid leaves her body.
Courtney Moore, 27, has lived most of her life in the Pitt County town of Farmville. The last time she took heroin was a year ago August, eight months before she learned she was pregnant. She’s remained in her treatment program throughout her pregnancy, taking a brand of buprenorphine called Subutex and attending counseling sessions.
Studies have indicated that continuing to take the treatment drug is the wisest course of action for both the mother and her baby. Going cold turkey can be a traumatic experience, and the success rate is low.
Best-case scenario, Moore’s daughter will leave the hospital after 72 hours. Her chances of full recovery are very good, because, under the circumstances, her mom is giving her the best chance she can.
Advocates from a local chronic pain initiative are assisting mother and child in securing the care they need, and in preserving Courtney Moore’s dignity.
Heroin use has risen dramatically in the U.S. According to a July Centers for Disease Control and Prevention report, between 2002 and 2013 the rate of heroin-related overdose deaths nearly quadrupled. More than 8,200 people died in 2013.
Confirmed heroin-related deaths in North Carolina rose from 50 in 2007 to 170 in 2013.
The CDC also found that since 1999, deaths from opioid overdose has risen more precipitously among women (400 percent) than men (265 percent). With that has come a spike in neonatal abstinence syndrome – babies born with an opioid dependence.
According to N.C. State Center for Health Statistics data, from 2004 to 2012 North Carolina experienced a 511 percent increase in infants diagnosed with neonatal abstinence syndrome.
A study published in 2012 in the Journal of the American Medical Association found that the average hospital stay for a baby without NAS is 3.3 days; the average stay for a baby born with NAS is 16.4 days, at an average cost of care of $53,400.
Moore is receiving assistance from the chronic pain initiative program offered by the Community Care Plan of Eastern Carolina, one of the 14 regional networks within the Community Care of North Carolina, or CCNC, system. The program is designed for women who have chronic pain, a substance disorder or a mental health issue.
Program coordinator Chris Smith said often a woman who’s in a buprenorphine program is denied pain medication in the labor and delivery unit.
“Just because the patient is in treatment, doesn’t mean you ignore acute pain,” she said. “But there’s that stigma.”
The objective of the initiative is to get a birthing plan in place early on, so that “everyone is on the same page,” Smith said, and to prepare the mother for what her baby may well experience.
Moore’s dad died of cancer when she was 11. She started drinking when she was 13 or so, began smoking weed when she was 18. She first sampled the harder stuff in her 20s.
“I was kind of rebellious,” Moore said, “but I wasn’t bad.”
First it was prescription drugs, a lot of Percocet; then, soon, heroin. A couple of her friends introduced her and her husband to it.
“I loved it. It made me numb,” she said. “It made my problems go away.”
She managed to keep her job at Roses in Farmville and to care for her son. Heroin was cheap – $10 was plenty enough to get high – and accessible.
She overdosed once, while alone.
“When you do it, you just want to keep doing it, because you think you haven’t got enough. And then you’ve got way too much.
“I thought I was gonna die.”
That didn’t stop her. What did was finding herself, her husband and her son in a homeless shelter, all their possessions padlocked up in what was no longer their trailer.
The landlord gave them plenty of warning to get the stuff out, Moore said. “But I was just in la-la land.”
Then, “It reality hit me, all of a sudden, I guess: ‘Dag. I’m really here.’”
She tried to get off on her own, taking Opana and other pain meds. Those cost more than the heroin, but a friend would provide them on credit.
“I wound up giving my car away.” For one long summer, she and her family were afoot.
‘Trying to be honest’
Moore eventually found her way to PORT Human Services in Greenville. Within a couple of weeks, she was in treatment.
She began attending substance abuse comprehensive outpatient treatment classes, and then was put on the buprenorphine. She still attends classes a couple of days a week.
After learning she was pregnant, Moore was told of the chronic pain initiative at Community Care, where efforts were underway to educate the medical community in what she and a rapidly rising number of women experience.
“We’ve got to figure this out,” Chris Smith said of the need to get pediatricians and other medical professionals more comfortable delivering babies and providing perinatal care for women with substance issues.
Concerned about the risk involved, doctors in rural communities refer these women to hospitals in urban areas, Smith said. Then the women often don’t get there because they lack transportation.
CCNC, in partnership with the state divisions of Medical Assistance and Public Health, now offers health care professionals a Pregnancy Medical Home course, aimed at improving the quality of maternity care and maternal and infant outcomes while reducing health care costs.
(Another resource is the North Carolina Pregnancy & Opioid Exposure Project’s “Pregnancy and Opioid Exposure: Guidance for North Carolina.”)
CCNC’s program outlines for doctors what to do when confronted with substance disorders. The task is now to instill the program’s principles throughout CCNC’s network of medical homes.
“It’s a process,” Smith said.
Moore, meanwhile, edges forward in her own process. What lies ahead for her will not be “a normal, Discovery Channel” birthing experience,” said Rachel Warner, a CCPEC nurse case manager.
“These moms have already judged themselves, and feel guilty, though they’re trying to do the right thing,” she said. “And then they’re pregnant, so they feel even more guilt.”
“They’re trying to be honest,” Warner said. “They’re in treatment.” Still, they’re treated differently in the health care system. “It’s a struggle,” she said.
Warner, in Smith’s words, will be there to “bulldog it” for Moore, if that’s what’s required.
Her daughter’s drawings
Courtney Moore is putting her baby up for adoption.
Her son just turned 8. “I can’t take care of another child right now,” she said. She and her son are living with her mom in Farmville right now. “I’m still trying to get on my feet.”
She’s met the couple who will adopt her little girl, and really likes them. That means a lot to her. “I feel like I’m lucky. The baby’s lucky.”
Her baby is small, which is to be expected, but seems to be doing well.
Moore now contemplates her own future: “I don’t even know what I want to do.”
“You’ve got the makings of a great future,” Smith assures her.
“I’m hopeful,” Moore responds, and laughs just a little.
“You can have so much pride in what you’ve done already,” Smith says. She acknowledges how hard it must be for Moore to put her daughter up for adoption. “It’s probably as hard as it is to get clean, and stay clean, to make that decision.”
“I’m not looking forward to that day,” Moore replies.
Thereafter, she says, she’ll probably never try to make direct contact with her daughter – “I don’t want to make it hard on her when she gets older, thinking she has two mommies” – but would love to be sent pictures she’s drawn.
So she’ll work to maintain a good home for her son, she says, and treasure the pictures she’s sent from her daughter.[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]