In New Haven, addiction treatment options for pregnant women can lead to healthy babies

This story originally appeared in the New Haven Register and was written by Esteban L. Hernandez. 

NEW HAVEN >> Taking the heroin was easy for the woman.

She had already spent several years popping pills, using Percocet well after the medication was no longer needed for her surgery recovery.

By the time she met a man who would end up fathering her child, trying heroin came easy.

It was October 2014. The two walked on West Haven beach after snorting the drug. She hardly felt anything the first time; she figures he gave her a puny amount, not wanting to waste too much and with her high tolerance for opioids, it translated to having little effect.

“It was toxic,” said the woman, who agreed to an interview with the Register as long as her name would not be used. “The base of that relationship was solely drugs.”

She said she used to get high simply because she enjoyed it. She then got another reason — health-related — for her to try another drug to get high. She took the opioid medication Dilaudid (hydromorphone) while she was treated for ovarian cancer. She didn’t stop taking Percocet during this time. She later developed a heroin addiction after using in 2014.

Something clicked, though, in spring 2015. Maybe it losing her job over stealing $80 for drugs, or the dead-end relationship fueled by drug use. Maybe it was the thought of losing contact with her family that left her ready to embark on a new path.

“I was just tired. I was tired of being tired,” she said.

A day after starting methadone treatment at a New Haven clinic in March 2015, she had another reason to address her addiction. She was pregnant, which was shocking because of the implications it presented, and because five days earlier at detox, a pregnancy test had been negative.

She’s now the proud mother of a healthy, 9-month-old girl who she calls her life. The new mom has been treated with methadone since March 2015 as at that point, she decided the best thing for her was to continue using methadone while pregnant.

Methadone is used to treat people who abuse opioids . The addictions are to heroin, oxycodone and variations and mixtures of prescription painkillers or illicit drugs containing opioids.

According to research from the Behavioral Health System Baltimore, more than 8,403 pregnant women were admitted to government-funded programs in the U.S. for opioid use disorders in 2012, up from 2,748 in 1992. It’s a small number compared to the estimated 2 million people with opioid substance use disorders, yet those figures are somewhat deceiving; the data shows that during that time, the proportion of pregnant women who received medication assisted treatment dropped from 65 percent to 46 percent.

The mom of the 9-month-old said the baby child was born by cesarean section and was healthy, though she had some tremors. She was a little light at six pounds — a little peanut, the new mom said — but after four days in the hospital, the two were discharged and the baby did not continue on the medication.

This means that the overall number of pregnant women receiving medication has decreased, despite research proving its safe to use and even beneficial to a fetus, according to BHSB’s Dr. Mishka Terplan, who is also a ob-gyn physician. Terplan said there are other factors contributing to this drop, but he said it’s still “concerning.”

The new mom is one of several women in the city who are pregnant, receiving addition treatment and hope to have a healthy baby.

“Now looking back, I’m glad I stayed on,” she said. “I was so early in my treatment. I could have been a statistic.”

A 27-year-old woman who is now pregnant faced a similar decision about using medication-assisted treatment after she learned she was expecting. When she learned she was pregnant, she wasn’t using opioids after entering rehab, but still had cravings. The pregnant woman, who also is not being named to protect her privacy, said she started using Percocet prescribed for medical reasons; in her case, she was 16 and it was used to address endometriosis, which causes intense discomfort during her period.

But then she started using the Percocet “here (and) there for fun in high school,” she said.

Several years later, she developed gallstones. The prescription this time? Roxicodone, which contains oxycodone. She was taking three, 30 milligram oxycodone pills a day at the height of her addiction.

Now eight months pregnant and sober for more than a year, with a baby girl due this month, she is employed and has the support of her mother and fiance. She hasn’t told everyone about the medication she’s taking, Subutex (buprenorphine) which works like methadone but isn’t as strong. It’s another safe option her doctor told her to take after she learned she was pregnant.

She knows it’s helping herself and her child. But she feels like she’s using.

“To have to get up every morning to make sure I’m OK, I still feel like I’m dependent on something,” she said.

ADDICTION MEDICATION DURING PREGNANCY

Dr. Andrea Desai said she has always been fascinated by pregnancy, which she said is a “remarkably” healthy experience for a majority of women. An instructor at the Yale School Medicine, Desai is a second-year maternal-fetal medicine training fellow at the school’s Obstetrics, Gynecology and Reproductive Sciences Department. Desai practices maternal-fetal medicine, a specialty within OBGYN medicine, at the Yale Maternal-Fetal Medicine clinic.

Most pregnant women receiving addiction treatment are typically treated with methadone or buprenorphine, Desai said. Desai said these medications are maintenance therapy, which helps a mother and a child wean off other opioids.

“Pregnancy is a very stressful time,” Desai said, noting the stress is physical, emotional and mental. “For patients who are struggling with addiction, it can be very tempting to still use those substances to navigate emotional fluctuations.”

Coupled with stress, a pregnant woman with cravings can find herself in a difficult position of wanting the drug. However, this could give added motivation to an expecting mother to seek addiction treatment to ensure the safety of their child.

“These are two competing interests that these women are dealing with,” Desai said.

The new mom had been dealing with her own embarrassment over having to take methadone during her first visit. Then, she had another, developing life inside her. Her biggest fear was passing along the addiction. “I realized that I had to stick to my guns,” she said. “It wasn’t for my life. It was my daughter’s life. I didn’t want this child taken away.

The still pregnant woman gets more ultrasounds than most pregnant women but said her baby is doing fine. Using the buprenorphine also helps with pain management for her endometriosis, in addition to helping stave off urges.

Mothers may need to continue taking medication after the child is born. Some mothers will breastfeed while taking methadone, a practice some may find controversial, Desai said. This another vital experience that helps a mother bond with her child.

“Really small amounts of methadone or buprenorphine can be found in breast milk,” Desai said.

The American Congress of Obstetricians & Gynecologists supports breastfeeding for women who are receiving methadone or buprenorphine, noting in a May 2012 committee opinion that, “effects on the breastfed infant are likely to be minimal and that breastfeeding is not contraindicated.”

“It’s probably beneficial, in fact, when the baby is experiencing symptoms of withdrawals,” Desai said.

Methadone is more potent than buprenorphine, so depending on several factors, doctors can chose which medication is more suited for an individual. Historically, methadone has been used most often to treat pregnant women, but prescribing buprenorphine has also become common. The drugs help reduce cravings by helping a person maintain a controlled opioid consumption without its euphoric effects.

After determining proper dosage of the medication, expecting mothers will take the medication, which Desai said, “reduces stress to the fetus, reduces the urge to continue to use and thereby promotes maternal health and fetal health.” The dosage of the medication can increase during the third-trimester (final phase) of a woman’s pregnancy, Desai said.

Terplan said that a pregnant mother using an opioid like heroin, and even other individuals using such a drug, aren’t necessarily taking the drug to get high; they’re taking the drug to stave off withdrawal symptoms.

“For most people who use heroin, they’re not getting high, they’re just getting less sick,” Terplan said.

For a pregnant woman, avoiding withdrawal symptoms can be paramount in ensuring the fetus’ health.

“When mom’s in withdrawal, the fetus withdraws,” Terplan said. “A healthy mom is a healthy baby.”

Providing methadone or buprenorphine to an unborn fetus through a woman’s placenta may seem unsettling, but Desai that such a decision is made by balancing risks and benefits for the fetus.

“From our perspective as providers, the benefits of keeping a woman on a more stable dose and away from illicit drugs outweighs the risk of methadone medication,” Desai said.

It’s possible that a child born to a mother undergoing medication-assisted treatment could develop neonatal abstinence syndrome — infant withdrawals. This is due to the child getting used to receiving small doses of medication. Symptoms of the condition can include tremors, poor feeding and irritability.

However, this usually subsides within five days, Desai said. It’s an expected side effect, but treatable.

“Fortunately, it’s a short-term problem,” Desai said. “Once they navigate the withdrawals, there haven’t been any long-term poor outcomes associated with that.”

Some side effects of pregnant women taking medication can include premature birth and low birth weight. But children born with these kinds of conditions are not necessarily due solely to their mother’s medication therapy. A mother may have other contributing factors, such as poor diet. “It’s difficult to attribute just to the medication,” Desai said.

Most patients at the Yale clinic are usually already using medication and are often referred to the clinic after intake at Yale-New Haven Hospital, Desai said. At Yale-New Haven, doctors will administer dosages of methadone to a pregnant woman to help determine the correct amount. This process can take several days, with the goal of finding the optimal dose.

Using illicit opioids while pregnant can lead to serious complications. These include miscarriages, premature births and stillbirths.

“The dangers aside from the drugs, like heroin for example, (is) when you buy it off the street, you don’t know what else could be cut in it,” Desai said. Street-bought heroin is typically a cocktail of powdered chemicals; in addition to being cut with other illicit drugs like cocaine, it can also be cut with chemicals not made for human consumption.

There could also be serious consequences for babies whose mother’s don’t address withdrawal symptoms. Terplan said stress can affect the fetus’ growth, lead to a pre-term birth and possibly lead to chronic diseases later in life. Terplan said one of the reasons using methadone and buprenorphine is helpful for pregnant women is because it’s long-lasting and can help keep someone medicated for extended periods.

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