I live in the heartland of the opioid epidemic on the Vermont-New Hampshire border, where I practice and teach medical students and residents in a hospital nursery. Ten percent of newborns here are physically dependent on opioids due to maternal use during pregnancy. That’s two kids in each kindergarten class. Or, to look further into the future, about 50 kids in our local high school. What will school be like for them? Home? How will they fare?
I have become an expert on managing newborn opioid withdrawal. But I have little idea about what the long-term developmental outcomes will look like. The best we know, from sparse research literature, is that children exposed to opioids in the womb may be academically below their peers. We don’t know if there is anything we can do in early childhood to mitigate this. Nor do we know to what degree the coexistence of childhood poverty, neglect, or foster care contributes.
That knowledge is necessary for us to develop the right course of treatment for opioid-addicted babies, but it’s nowhere within reach. Though opioid addiction is higher in pro-Trump counties, the administration’s plan to fight the crisis is misguided and insufficient. It is allocating too much to law enforcement and too little to research and treatment.
The fear of jail prevents some women from getting the care that they need. All medical organizations recommend that women are prescribed “medically assisted treatment” – therapy with methadone or other medications that stave off withdrawal symptoms. This type of treatment prevents maternal relapse, lowers maternal mortality and preterm delivery. In my region, most mothers seek and receive such treatment.
But in the 24 states where pregnant women who use drugs can be charged with child abuse, women are reluctant to disclose their disorders. These are the mothers who overdose, deliver early, and are still seeking drugs when they become parents. They are unable to care for their new child. These laws should come off the books now, to save lives and protect children by helping their parents function as parents.
A second needed change is a lifting of restrictions on inpatient substance abuse treatment beds where mothers can live with and care for their babies. Women who know they need a safe haven from bad influences at home nonetheless remain there, placing themselves in risky environments rather than entering standard inpatient drug rehabilitation facilities, where they would be separated from their newborns. Federal Medicaid regulations limit bed numbers per facility to 16. In New Hampshire, we have 32 mother-baby rehabilitation beds, but close to a thousand opioid-exposed newborns each year.
We also need more research on the health of these babies, including a better evidence base regarding care environments, ideal use of medications for newborns with severe withdrawal, and what supports to put in place once they are at home. It makes more sense to invest in this research now – when the children are young – than to wait and address any issues that might arise when they’re older and haven’t benefited from the rights kinds of early intervention.
Understandably, most of us feel a significant amount of sorrow for newborns that are suffering greatly through no choice of their own. Anger at their mothers is a natural human reaction. But for many young women, the underlying antecedents of addiction are their own childhood traumas – broken homes, neglect, physical and sexual abuse. Opioids numb emotional pain as well as physical pain; they are just as addictive regardless of the reason one begins taking them.
These mothers need sufficient treatment alongside their babies, and for support services so they can avoid relapse and be good parents. Though mothers of many of the babies I care for succeed in drug treatment programs during pregnancy, rates of relapse are significant. While it is somewhat easier to access drug treatment programs while pregnant, needed treatment and supportive services can disappear after birth. Medicaid coverage for new mothers ends 60 days after delivery. We can discharge a baby home with a mother who is doing well, only to find out she died from a relapse months later.
Thinking ahead to the kindergarten classes of 2023, the public needs more research into the best ways to care for those who are born dependent on drugs. Withdrawing newborns are hard for parents, or anyone, to care for. They have tremors and bad diarrhea. They have trouble eating and gaining weight. They cry a lot. They don’t sleep well and are hard to console. And they are often separated from mothers who battle their own addiction.
We can’t stand by as a generation is raised in foster care or orphaned. We must act now.
Alison Volpe Holmes, MD, MPH is an associate professor of pediatrics at the Geisel School of Medicine at Dartmouth, and a 2018 Public Voices fellow.