Amy is a lovely young woman. She works full time and just bought a house with her husband. Her favorite color is pink and she fosters dogs that don’t have a home. She would love to start a family.
But she can’t.
After a long battle with Oxycontin and heroin, she in now on methadone. Amy does not want her baby born addicted to opiates.
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I don’t blame her.
Every hour, one infant is born addicted to opiates in the United States.
If you spend time on the pediatric ward at Boston Medical Center, you will hear it: the shrill cry, a symphony of high-pitched screaming created by babies withdrawing from opiates. Sweaty, angry, and tremulous, these infants suffer from neonatal abstinence syndrome (NAS). Tricky to treat, expensive, and without known long-term effects, NAS is on the rise.
Rates of NAS in newborns have increased 3-fold over the past decade, according to the most recent data.1
These babies are the evolving outcome of the growing opiate market, especially among women of childbearing age like Amy.
Amy’s addiction to drugs started at age 13 with alcohol and marijuana. She began taking Percocet at age 15. One day, while looking for Percocet, she was given Oxycontin. Her addiction to opiates transformed overnight.
By 19, she tried heroin for the first time.
Amy said, “I was told that heroin was just a cheaper Oxycontin, really, and that I could spend $10 for what I was usually spending $40-$50 for. This, of course, was intriguing, and is what usually causes most opiate addicts to turn to heroin.”
Amy’s case is not unusual. The abundant supply of prescription opiates has created a profound spillover into the heroin market. This has caused a national crisis, disproportionally affecting women.
Women face tougher challenges navigating opiate addictions than men. They progress more quickly from recreational use to dependence (known as telescoping), they’re more susceptible to relapse, and they develop the social consequences of addiction faster than men.2
Women bear the weight of bringing addicted children into the world.
A few years ago, I took care of a young woman admitted for heroin overdose after failing her third detox. She begged, “Doctor, please help me.”
I referred her to a local methadone clinic. The clinic was based on a lottery system. She would show up every day at 8 am, and wait for her name, which may or may not get called.
What her records didn’t show was that she’d already tried this clinic. She had shown up every day for a week. Her name was never called.
Three days after discharging her from the hospital, with the advice to again try the methadone clinic, she was found dead, stripped of all her clothing.
Like my patient, Amy did not want to be addicted. She does not wish addiction on her worst enemy. Desperate, she tried detox.
“Detox lasts from three to five days and it’s just a place to sit around and kill time while you are given doses of methadone. In theory this is great, in practice it only gets you so far. There are a thousand tiny, little fragments that make up an addiction, and the physical withdrawal is a comparatively small one,” said Amy.
Within 24 hours of her first detox, Amy relapsed. This experience is the norm.
Limited funding and a paucity of research have led to poor outcomes for addicts with even the best intent. Each year, federal and state governments spend $500 billion on health care costs related to addiction, but less than 2 cents per dollar is spent on research and prevention.3 As targeted therapy and individualized treatment plans are skyrocketing for cancer, diabetes, sickle cell, and other diseases, addicts are left in an outdated paradigm that if a treatment works for one, it must work for all.
Although Amy’s first detox didn’t work, trying again was her only option.
She recalls, “So began the cycle of four detox stays, all very much like the first. Finally, the place that was paying for my stays had enough and would no longer pay. The thing is, simply using detox programs that do not include any individualized time admitted to inpatient rehab directly after is not enough to get anyone to stop using.”
Fortunately for Amy, she was introduced to methadone by a friend. He gave her “enough methadone to detox.” Although her first experience with methadone didn’t dampen the addiction, it motivated her to find a methadone clinic that could help.
Since that fourth try, Amy has not used heroin in 8 years.
While methadone saved her life, it’s now preventing her from starting a family.
The choice between conceiving a child addicted to methadone and trying to wean herself off before pregnancy (with a significant chance of relapse) is the decision Amy is faced with.
There’s no consensus in the medical literature about how to assess readiness to taper methadone: no formula or proven time in maintenance therapy that leads to a successful detox.
For Amy, this unknown is terrifying.
“While waiting in line to be dispensed methadone, you hear horror stories from people who tried to get off methadone and failed. It makes me think: what if I take too long to get off of methadone and miss my chance at having a baby? Or worse yet, what if I accidentally got pregnant while still on methadone? But then, what if I hurry along and detox off methadone, and suddenly relapse, now with a child?”
As a provider who cares for infants with NAS, it is difficult to give babies morphine and not relieve their suffering, or to push a nasogastric tube up their noses because they are too jittery to eat, or to see their bottoms excoriated by uncontrollable diarrhea.
While treatment of NAS remains difficult, the real failure of our system is apparent when the mom says, “I was an NAS baby too.”
There are no national standardized protocols to help these babies or mothers.4 There are no long-term studies that look at outcomes and what these babies need as they grow. There are minimal studies addressing tailored therapy for infants withdrawing from opiates.
To avoid this, Amy has made the decision that she will not have children until methadone is completely out of the picture, even if it means she’ll never conceive.
She has started the 1.5-year-long process of weaning her methadone.
The odds are stacked against her, with literature reporting high rates of relapse, up to 50% among women.4 Unlike other diseases, the intricacies of keeping addiction at bay are not as clear to the medical world. Even a clinic’s best efforts often leave patients feeling alone in this difficult process.
Regardless, Amy is determined to not be another statistic…
“I will make this work. I have to. I only hope that my single-minded ferocity is enough.”
Reference
- 1 Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA. 2012;307(18):1934-1940.
- 2 The National Center on Addiction and Substance Abuse at Columbia University. The Formative Years: Pathways to Substance Abuse Among Girls and Young Women Ages 8-22. New York, NY: Columbia University. February 2003.
- 3 McVay DA, ed. Drug War Facts. Lancaster, PA: Common Sense for Drug Policy. 2007. www.drugwarfacts.org.
- 4 Patrick SW, Kaplan HC, Passarella M, Davis MM, Lorch SA. Variation in treatment of neonatal abstinence syndrome in US children’s hospitals, 2004-2011 [published online ahead of print June 12, 2014]. J Perinatol. doi: 10.1038/jp.2014.114.
