By Taylor Knopf
Randi Cranny, 23, was three months into methadone treatment at Johnston Recovery Services when she discovered she was pregnant.
“My first thought was that I needed to quit or I needed to taper my treatment,” she said.
This is the knee-jerk reaction for a lot of pregnant women in her situation. However, the medical community recommends the opposite.
On Tuesday, the American College of Obstetricians and Gynecologists reaffirmed its recommendation that pregnant women with an opioid use disorder should seek medication-assisted treatment.
“Medication-assisted treatment improves adherence to prenatal care and addiction treatment programs and has been shown to reduce the risk of pregnancy complications,” said lead committee opinion author Maria Mascola in a press release.
“And while neonatal abstinence syndrome is often seen in infants who have been exposed prenatally to opioids, it is important to remember that it is an expected and treatable condition that has not been found to have any significant effect on cognitive development,” she wrote.
Cranny’s baby is one of a rising number of infants with Neonatal Abstinence Syndrome (NAS), a condition where newborns experience drug withdrawal shortly after birth. It’s caused by the mother using an opioid during pregnancy, such as oxycontin, methadone or heroin.
In North Carolina, the number of infants with NAS increased more than 50 percent from 2004 to 2012, according to North Carolina Pregnancy & Opioid Exposure Project, and that was before state officials really began to talk about the opioid crisis.
With those infants come costs for treatment, as well as treatment for mothers to recover and parent successfully. But there are opportunities, too.
Rising rates, costs
Nationwide, 21,732 infants were born with NAS in 2012, which means about every 25 minutes a new baby suffers opioid withdrawal symptoms, according to the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health. That’s a five-fold increase since 2000.
It’s possible for infants with NAS to experience a range of symptoms, such as trembling, excessive or high-pitched crying, sleep problems, seizures, yawning, stuffy nose, sneezing, trouble feeding, vomiting, diarrhea, dehydration, sweating or fever. Every baby’s situation is unique, and they don’t all suffer from every symptom.
Newborns with NAS have hospital stays that are eight times longer than for average newborns. In 2012, infants with NAS stayed an average of 16.9 days accumulating, on average, about $66,700 in hospital costs. Most babies without complications stay about two days, costing only about $3,500, NIDA reported.
All told in 2012, infants with NAS cost hospitals about $1.5 billion nationwide, 81 percent of that cost was borne by state Medicaid programs, NIDA calculated.
Attacking the problem with gentle touches
While opioid use during pregnancy is not something to take lightly, the good news is that NAS is treatable. Also, there appear to be no long-term negative consequences for babies exposed to opioids in the womb.
There has been a lot of media sensationalism surrounding people with opioid use disorder and babies born with NAS, said Hendree Jones, a professor at the University of North Carolina Chapel Hill in the School of Medicine’s Obstetrics and Gynecology Department.
“We have very good tools to identify, track and treat neonatal abstinence syndrome,” she said.
The Finnegan Neonatal Abstinence Scoring System is a tool doctors use to assess whether a newborn has NAS by scoring and logging different behaviors, such as how often the child cries or how long they sleep after eating.
“Our interaction and contact with babies can make it better or worse,” Jones said.
She said breastfeeding and skin-to-skin contact is highly encouraged. Dim lights, soft voices and a calming environment make a big difference when it comes to withdrawal symptoms.
“Hospitals are moving away from separating mom and baby. If we keep them together, we cut the rate of babies that need treatment in half,” Jones said.
If an infant does need treatment, Jones said the policy at UNC Hospitals is to give the baby low doses of morphine. Other institutions use methadone to treat NAS in the hospital.
Jones is also the executive director of UNC Horizons, a program that helps mothers from across North Carolina recover from various substance abuse issues.
During 2015-16, Horizons helped 220 women through addiction treatment and recovery services. About 95 percent of those women graduated the program with stable or good Child Protective Service outcomes.
Jones said the program initially started to help mothers with cocaine addiction. But in recent years, Horizons has seen a shift to opioids. Last year, 56 percent of women that came to Horizons had a primary diagnosis of opioid addiction, Jones said. The second most common substance is still cocaine, she added.
Cranny listened to the advice of her counselors at Johnston Recovery and continued methadone throughout her pregnancy. That was smart, said Sarah Hess, a counselor at Johnston Recovery who leads a pregnancy support group.
“For the baby inside trying to develop, these extreme highs and lows of the mother cause stress the baby. It can cause miscarriage and you are risking below average weight, prematurity and stillbirth.”
When a mother is in medication-assisted treatment, she stays at one constant opioid level, Hess said. There are no highs and lows associated with methadone, as it’s a monitored daily dose.
While only half of babies exposed to opioids in the womb need treatment after birth, mothers still fear this possibility.
“They all hope their babies don’t need the medication,” Hess said. “They all know what withdrawal feels like and they don’t want their babies to feel that either. In pregnancy group, we talk about a lot of this and processing the guilt that comes with it.”
Even so, as Cranny laid in the labor and delivery room at WakeMed, she again thought back over her pregnancy and wondered if she should have continued her treatment.
“But if I had quit and had a miscarriage, we wouldn’t even be here right now. It would have been worse. A miscarriage would have made me start using again,” Cranny remembered thinking.
She gave birth to a 5 pound, 13 ounce healthy baby girl. Cranny, her boyfriend and their 2-year-old son Bentley were able to stay at in the Ronald McDonald House at WakeMed for 11 nights as the newborn received methadone treatment.
Cranny and her family are back home and everyone is doing well. She is already starting to taper off methadone.
She said she was proud of herself for making it through the entire delivery without any medication. She started abusing opioid pills after the birth of her first child during a time of postpartum depression. She said she considers herself lucky that those around her wouldn’t give her heroin when she asked for it.
When she decided to get into recovery, Cranny said her father and boyfriend were very supportive.
“Johnston Recovery is the place that saved my life,” Cranny said.
“They get to know everyone on a genuine level. I don’t have to say I’m having an off day, they can just tell. They already know if I’m not being myself. They get to know the clients so well. I feel like I can tell Sarah anything,” she said.
Fighting for joy
Cranny is unique in that she’s open to telling her story. She knows she did what was best for herself and her baby.
There are stigma and shame associated with substance abuse combined with pregnancy. Hess helps her clients purge themselves of any guilt they feel.
“There is an element of joy around pregnancy,” she said. “Everyone wants to have a healthy baby. Everyone wants to be a good mother. There is a real misconception that these are women that don’t care and choose drugs over their babies.”
Jones does the same at UNC Horizons.
“We work with the women to separate their behavior and experiences from themselves,” she said. “What they have lived through before they walk into treatment is anything short of miraculous.”
She added that women are more likely to abuse pills than men, and they are also subject to more violence and abuse than men.
“We are helping to heal the whole person and focus on mother-child dyad,” she said.