This story is an expanded version of a page that appears in the September 2017 issue of National Geographic magazine.
Babies going through opioid withdrawal have a distinct way of crying: a short, anguished, high-pitched wail, repeated over and over. It echoes through the neonatal therapeutic unit of Cabell Huntington Hospital in Huntington, West Virginia. A week-old girl has been at it, inconsolably, since six o’clock this morning. At 10 o’clock Sara Murray, the unit’s soft-spoken, no-nonsense nurse manager, sighs. “This may be a frustrating day,” she says.
The opioid epidemic in the United States is painfully evident in hospital newborn units across the country. In 2012 nearly 22,000 babies were born drug dependent, one every 25 minutes, according to the most recent federal data. As the opioid crisis has escalated dramatically over the past five years, those numbers have surely climbed.
West Virginia, at two and a half times the national average, has the highest rate of deaths from drug overdose—mostly from opioids. Cabell County, which averaged about 130 overdose calls to 911 annually until 2012, received 1,476 calls last year and is on pace to reach around 2,000 this year. Emergency workers saved many of those people, including an 11-year-old, but inpatient treatment programs have long waiting lists. At Cabell Huntington Hospital, one in five newborns has been exposed to opioids in the womb.
“What you’re seeing here is the tip of the iceberg of substance use,” says neonatologist Sean Loudin, the unit’s medical director.
In 2012 the neonatal intensive care unit became so overwhelmed by drug-dependent babies that it had to turn away newborns with other medical needs. The hospital opened this specialized unit to treat withdrawal. It typically has 18 babies. On this day there are 23.
The babies shake, sweat, vomit, and hold their bodies stiff as planks. They eat and sleep fitfully. Swaddled, they lie in bassinets or in the arms of nurses, parents, or volunteers. The place doesn’t have the hustle or beeping machinery of an ICU. Instead there are dim lights and hushed conversations because the babies need calm and quiet. Many also need methadone or other medication to relieve their symptoms. They are weaned from it over days or weeks.
“OK,” Murray whispers to a bleating 41-day-old boy. She gently lifts him to her chest, cradles him firmly, and places a green pacifier in his mouth. He sucks it fast and hard, like a piston.
Opioids pass readily from a pregnant woman’s bloodstream through the placenta and across the fetal blood-brain barrier. When birth abruptly shuts down the flow of the drug, the baby’s nervous system can trigger the agitating symptoms of withdrawal. Studies show that 55 percent to 94 percent of newborns exposed to opioids develop symptoms. Prenatal exposure to other widely used drugs, including benzodiazepines and certain antidepressants, also can lead to withdrawal shortly after birth.
The condition is called neonatal abstinence syndrome (NAS). Experts don’t consider it to be addiction, which, by definition, means a person persists in compulsive drug use despite terrible consequences. By the same logic, NAS is also a misnomer—abstaining, or just saying no, is different from experiencing the physical anguish of withdrawal. But medical experts have come to accept the NAS label because it’s less fraught with stigma than words like “addiction” and “withdrawal.”
In some cases the mothers themselves are in recovery. They didn’t misuse opioids during pregnancy but took methadone or buprenorphine, the frontline medications for treating opioid addiction. The American Congress of Obstetricians and Gynecologists recommends their use during pregnancy despite the risk of NAS, for the obvious reason that sobriety is safer and healthier for a woman than shooting heroin or popping painkillers or trying to go cold turkey on her own. It’s also much better for her child. But encouraging as it is, the growing use of medication-assisted addiction treatment means that even when the opioid crisis eases, hospitals like Cabell Huntington will continue to be swamped with babies in withdrawal.
To manage the condition, most hospitals use an assessment tool developed at the height of the heroin outbreak in the 1970s. Babies are rated every four hours on the severity of 31 symptoms, including excessive crying, sweating, tremors, and frequent yawning. The scores help doctors determine whether to put babies on methadone or other medication. In most cases the scores support drug therapy. Now some researchers are challenging that approach.
“It’s archaic,” says Elisha Wachman, a neonatologist at Boston Medical Center and an assistant professor of pediatrics at Boston University School of Medicine. “What ends up happening is that babies get overmedicated.” Too often, she says, they experience withdrawal from their treatment, which prolongs their misery and their hospital stay.
A handful of researchers around the country are revamping NAS treatment to rely less on medication and more on parental bonding. Wachman has abandoned the old score sheet for assessing the babies. “I couldn’t care less how many times they yawn,” she says. Instead, she evaluates them on just three measures: eating, sleeping, and being consoled. Rather than transfer babies to an ICU or a specialty unit, Boston Medical Center keeps them with their moms throughout their stay. Wachman encourages the women to breastfeed and clutch their babies skin to skin. One hundred fifty volunteers—most of them medical students and hospital employees—put in two-hour shifts as cuddlers. The waiting list to hold babies has 200 names.
Before the hospital changed its approach, 86 percent of the babies with NAS it treated received medication. Now it’s 30 percent. The babies generally spend nine days in the hospital, down from 19 days under the old protocol. The average cost of a hospital stay for a baby with NAS is $19,655 at Boston Medical Center, compared to a national average of $67,000.
Wachman says sound treatment for the babies must go hand in hand with compassionate, comprehensive care for their mothers. The medical center runs a prenatal clinic for women with addiction. The obstetricians prescribe buprenorphine and prepare women for the possibility that their babies will have NAS. The clinic also offers counseling, social services, psychiatric help, peer support, and education about infant care. “When the moms come in to deliver, they’re in the best shape they can be,” Wachman says. In July the medical center opened a clinic that provides pediatric care for babies born with NAS and addiction services for their mothers.
It’s not clear how opioid exposure affects long-term brain development. Surprisingly little research has been done, and most of it predates the current crisis and the widespread use of highly potent synthetics, such as fentanyl. Some studies show subtle cognitive and behavioral differences among children who were exposed to opioids before birth, but the problems are less severe than the intellectual and attention deficits associated with fetal alcohol exposure. The studies don’t answer a key question: Do the neurodevelopment issues stem from drug exposure or poverty or other chronic stresses? Some researchers believe that social factors and a stable environment are bigger influences on a child’s future than NAS.
“We keep hearing about the babies, and that it is important, but there needs to be much more of a focus on women and making sure they’re taken care of well,” says Uma Reddy, a maternal-fetal medicine expert at the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
Jordann Thomas was introduced to OxyContin in ninth grade. In her high school bathroom, a friend showed her how to crush the pill, dissolve the powder, fill a syringe, and inject herself. She tried heroin two weeks before she turned 16. The decade that followed was a blur of intravenous drug use, arrests, prison, probation, recovery, and relapse. At 26, she turned her life around. She credits a good recovery program and medication-assisted treatment.
She was on a standard treatment, which combines buprenorphine and another drug. When Thomas learned she was pregnant, her doctor switched her prescription to buprenorphine only, explaining that it was safer for the baby. She says nobody mentioned the risk that her baby might develop NAS until she went into labor and an intake nurse at her local hospital asked what medications she was taking. Her son was born weighing six pounds, 14 ounces, on an April afternoon. Twelve hours later he was rushed to the neonatal treatment unit at Cabell Huntington Hospital, nearly an hour away.
“That guilt I felt about using and hurting the people I was hurting when I was getting high was the same guilt that came over me when I found out my son was going to withdraw because of a drug I took that I was told was safe,” Thomas says.
She was terrified to learn he would be treated with methadone. And she felt sick watching his rigid little body sweat and twitch. “It was something awful trying to change his diaper and trying to get him to relax his leg,” she says. Nurses reassured her he’d be OK. One by one, his symptoms disappeared.
Unlike Thomas, few of the other moms were in recovery during pregnancy or received good prenatal care. “Our majority are women in desperate situations,” says Loudin, the medical director. Some don’t know the full list of substances they’ve taken or are too scared to talk about it.
Murray, the nurse manager, says treatment was relatively straightforward just a few years ago, when the main problem was painkillers and then heroin, and babies showed classic withdrawal symptoms. Now more babies have been exposed to heroin plus cocaine, methamphetamine, and whatever else is making the rounds. Recently a newborn didn’t respond to treatment until the medical team figured out that the baby had been exposed to gabapentin, an antiseizure drug that relieves pain and anxiety. It was the first sign that the drug had shown up on local streets. “We’re seeing all kind of bizarre symptoms we are not prepared for,” Murray says.
Many babies now need care longer. Thomas’s son has been here five and a half weeks. On a recent afternoon he lies on his back in a clear bassinet, sleeping with his mouth slightly open. Thomas strokes his belly and feels his diaper. His eyelids flutter, but he doesn’t stir. “Without this program, I don’t know where I’d be,” she says.
He weighs more than 10 pounds. He scores well on tests of hearing and visual perception. He smiles a lot and flings his arms playfully. He’s scheduled to be discharged in two days.
“We’re ready to go home,” Thomas says. “Finally.”
Fran Smith is a freelance writer and editor. Max Aguilera-Hellweg is a photographer who also trained as a medical doctor.
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