Heroin's hold: For pregnant women battling opioid addiction, more at stake than just breaking the habit

June 19, 2016 | 5:00 am
Haven mixes a cup of water with her dose of methadone, which she receives at the Cedar Rapids Treatment Center on Monday, May 23, 2016. The medicine is lightly flavored, but still retains a bitter taste and water is the only way to mitigate it. Haven suffers from migraines and Fibromyalgia—chronic pain, and she became addicted to opioid pain killers after a Cedar Rapids doctor prescribed them to her in 2006. (Rebecca F. Miller/The Gazette)
Chapter 1:

A perilous start to life

Elle doesn’t want her son to be born an addict.

She started using drugs when she was 17, she said, to self-medicate and forget her past. Her mother used drugs while she was growing up and it came easily to Elle.

Heroin's hold in Iowa

For the last three weeks, Gazette reporters have been taking an in-depth look at the opioid epidemic in Iowa. This story focuses on pregnant women who are battling addiction.

 

Woman icon by TukTuk Design. Police icon by Icons8, RU. Pacifier icon by TiRo. Syringe icon by Edward Boatman. All icons from the Noun Project.

As with so many heroin users, Elle first abused prescription painkillers, moving on to heroin when the makers of OxyContin stopped making pills that easily could be crushed and then snorted or injected.

About two years ago, she overdosed on Krokodil — a synthetic opioid cooked similar to methamphetamine with items such as gasoline and paint thinner.

That put her in the hospital and then jail.

The former heroin addict is now 14-months clean and seven months pregnant. She got clean through the help of the Cedar Rapids Treatment Center — a medication-assisted treatment facility that provides therapy along with methadone or suboxone. Elle gets a daily dose of methadone, a prescribed drug that helps stop withdrawal symptoms and the cravings associated with opioid use. It’s helped her get her life back — she has a job and is in a committed relationship.

“I am dependent on” methadone, Elle said. “I didn’t want to be dependent on anything. I talked with my OB-GYN to see if I could get off it, but he didn’t recommend it.”

If she were to stop taking her daily methadone doses she could go through withdrawal — which is painful and puts the body through immense stress. This could cause miscarriage or early labor.

Continued methadone use is safe for pregnant women, research shows, and Jackie Scott, clinic director of the Cedar Rapids Treatment Center, said the clinic works closely with pregnant clients’ doctors to put the women on appropriate methadone doses and to monitor mom and baby.

But Elle’s continued methadone use also means there’s now a possibility her son will go through mild withdrawal come Aug. 18 — her due date.

“If he’s born addicted, how will that start off his life?” she said. “But I’m going to try everything I can do to not be my mother.”

Addicted in the womb

Since 2002, the number of female heroin addicts has sky rocketed, rising 100 percent, according to the Centers for Disease Control and Prevention. From 2002 to 2004, only 0.8 out of every 1,000 women was addicted to the drug. But from 2011 to 2013, that number doubled to 1.6 per 1,000 women.

All drug and alcohol use can negatively impact a fetus — resulting in higher risk of stillbirth, preterm labor and low birth weight, and cognitive or behavioral problems later in life, medical experts said. However, heroin and opioid use is most likely also to cause neonatal abstinence syndrome — also known as withdrawal.

 

Opioid withdrawal is a painful process. Heroin users interviewed for this Gazette series spoke in detail about the misery, pain and sickness that come when the highs stop.

That’s also the case for the country’s tiniest addicts — babies exposed to opioids in the womb.

There was a fivefold increase in the number of babies born suffering from opioid withdrawal from 2000 to 2012, according to a National Institute on Drug Abuse study. In 2012, there were 21,732 infants born with neonatal abstinence syndrome — that equals to one baby every 25 minutes.

“All babies cry — but this baby will cry,” said Dr. Roger Allen, director of the neonatal intensive care unit at Mercy Medical Center in Cedar Rapids. “He will thrash and act like someone who is in pain.”

Babies born addicted to opioids can struggle to breath, they’re extremely fidgety, prone to seizures, fussy with a high-pitched cry, and have problems feeding.

“There are supportive measures we can take,” said Dr. Andrew Nordine, medical director of the NICU at UnityPoint Health-St. Luke’s Hospital. “We can do a tight swaddle and put them in a quiet environment.”

If withdrawal is serious enough, the baby may be put on morphine or methadone to help wean him or her off the opioid, Nordine said, adding babies can stay in the NICU up to two weeks for neonatal abstinence syndrome.

Dr. Andrew Nordine is the director of the neonatal intensive care unit at UnityPoint Health-St. Luke's Hospital in Cedar Rapids on Wednesday, June 15, 2016. He says the NICU tries to provide a supportive environment for babies experiencing withdrawal symptoms. (Rebecca F. Miller/The Gazette)
Chapter 2:

Identifying mothers

Corridor hospitals work diligently to identify pregnant women struggling with substance abuse through an interview and screening process, Allen said.

“We’re good at picking up on that and getting them involved with programs like (Area Substance Abuse Council’s) Heart of Iowa,” he said. “There are a few moms who don’t come in for an OB appointment, and we have to deal with that when they show up in labor.”

Pregnant mothers in Iowa who are receiving treatment for substance abuse

SubstancePrimarySecondaryTertiaryTotal
Methamphetamines 119 47 12 178 |
Marijuana/hashish 68 81 26 175 |
Alcohol 52 33 32 117 |
Other opiates/synthetics 13 15 12 40 |
Cocaine/crack 13 8 7 28 |
Benzodiazepines 3 4 11 18 |
Other hallucinogens 1 8 2 11 |
Heroin 4 4 1 9 |
Other amphetamines 0 3 2 5 |
Ecstasy 0 1 1 2 |
Other 0 1 1 2 |
Other prescribed analgesics 1 0 0 1 |
Barbiturates 0 1 0 1 |
OxyContin 0 1 0 1 |
Inhalants 0 0 1 1 |
Other Stimulants 0 0 1 1 |

Data made available by the Area Substance Abuse Council

St. Luke’s, Mercy Medical and the University of Iowa Hospitals and Clinics have a broad questionnaire that all pregnant women must fill out. It asks questions about everything from past drug and tobacco use to history of domestic abuse and child abuse.

Depending on answers to these questions — which are designed to weed out possible drug abuse — hospitals send the babies umbilical cords or meconium, the first stool sample from an infant, to an Illinois lab to test for the presence of illicit substances, said Kathie Manderscheid, manager of St. Luke’s Women’s & Children’s Center.

“The majority of babies born have their umbilical cords tested,” she said. “This cuts down on stereotyping.”

However, this screening process varies widely from hospital to hospital. The UI, several state agencies, the Iowa Hospital Association and Iowa Department of Public Health developed statewide screening guidelines in 2008 after realizing hospital staffs were undertrained and screenings happened randomly or not at all.

“We were missing cases,” said Dr. Resmiye Oral, a professor of clinical pediatrics and director of the Child Protection Program at UIHC. The state Department of Human Services “reported that children were discharged after birth and then a mother was reported for substance abuse.”

Multiple hospitals have adopted these guidelines, Oral said, and since then more babies have been identified and services have been offered to families immediately.

“The majority of pregnant women do their best to minimize drug use,” Oral said. “But people do not choose to abuse substances. They are self-medicating past traumas. It is unfair to expect them to go cold turkey and stop using.”

‘Tip of the iceberg’

Data from the Iowa Hospital Association shows that about 300 babies born each year have noxious influences — drugs or alcohol — affecting them. For these newborns and their families, treating the immediate health problems is the simple part.

Newborns born with drugs or alcohol influences in Iowa

YearDrug-exposed newborns
2010 299
2011 264
2012 308
2013 389
2014 312

Data made available by the Iowa Hospital Association

“Dealing with physical addiction is pretty easy,” Mercy’s Allen said. “Providing long-term support for families, a social situation where babies can thrive, that is what’s difficult.”

“The physical effects are the tip of the iceberg,” Oral agreed.

Living situations are chaotic, often plagued with unemployment, domestic abuse and poverty, experts said. And these childhood adversities can have more of an impact than the drug-exsposure itself.

Oral pointed to a study that looked at the effect of fetal drug-exposure on twins. One twin stayed with the family while the other was removed and adopted. When those twins were compared later in life, the adopted twin was doing far better than the twin who stayed in a chaotic environment. That twin experienced developmental delays and struggled in school.

“We need to look at substance abuse as a social risk factor that impacts children’s lives,” she said.

Drug-exposed children often deal with cognitive and behavioral issues, said Stacie Mitchell, a children’s therapist and clinician supervisor at Tanager Place. Her office is filled with toys and pillows, the lights can be dimmed and there always are snacks available.

“The biggest struggle we run into are kids coming in presenting behaviors of defiance, aggression, depression,” she said.

However, problems stemming from childhood trauma often are the same as children with Attention Deficit Hyperactivity Disorder. That means problems will persist if a child is put on ADHD medication instead of working on the root cause of the trauma.

“We need to do a thorough assessment,” she said. “If you go with just what you’re seeing, you’ll miss something.”

Drug-exposed children’s brains develop differently, she said, they have intense moods and emotions, throw tantrums, have overactive or underactive senses that cause them to be uncomfortable, and are impulsive.

“In the end, it doesn’t matter what the case is,” Mitchell said. “Trauma, substance abuse, ADHD — we need to know the cause and give the kids the help they need. The earlier you get a child in, the better the outcome.”

 

A nurse at the Cedar Rapids Treatment Center fills a cup with water as methadone is dispensed from a machine that regulates each dose on Monday, May 23, 2016. The medicine is lightly flavored, but still retains a bitter taste and water is the only way to mitigate it. (Rebecca F. Miller/The Gazette)
Chapter 3:

Keeping families together

The state works hard to keep families together, said Tracey Parker, the adoption program manager at DHS, a practice that has changed over the years.

“Back in the day, any time there was drug use the kids were removed,” she said.

But three years ago, DHS reworked the system it used to deal with child abuse and neglect. DHS agents now complete an assessment to determine if the child is safe.

If there’s an immediate risk, DHS will ask for a court order to remove the child from the home and work to place him or her with a family member or in the foster care system. However, if the child is not in eminent danger, the social services agency will offer supports and education to help both the family and child.

In 2015, about 4 percent of all DHS child protective assessments, or 880 children, had the presence of illegal drugs in their bodies, according to DHS data. Of those cases, about 558 children were less than a month old; heroin was present in seven cases, and prescription drugs were present in 74.

One program DHS uses to work with these families is Parent Partners, which pairs individuals who successfully have gone through the child welfare system with those who are in the middle of navigating it. The mentor provides advocacy for the family while also working to hold them accountable. It’s helpful, Parker explained, because families may be intimidated by a DHS worker while the Parent Partner is someone to whom the family can relate better.

For those children who are removed and later adopted, DHS works to give the adoptive families the necessary medical histories and education about drug exposure, she said.

‘Safer than painkillers’

Haven suffers from migraines and Fibromyalgia — chronic pain. In 2006, a Cedar Rapids doctor prescribed her long-acting morphine and large amounts of Oxycodone. It didn’t take long for her to get hooked.

Her physician, Dr. Winthrop Risk, was disciplined in 2009 by the Iowa Board of Medicine for violating standards of practice for appropriate pain management, “prescribing excessive controlled substances to numerous patients, including patients with known drug abuse histories,” according to board of medicine documents. The board found that at least three patients to whom he prescribed painkillers died of drug overdoses.

He paid a $10,000 fine and the board prohibited him from treating patients for chronic pain and prescribing controlled substances.

Meanwhile, Haven has spent the past four years working to overcome her addiction — an addiction she didn’t even realize she had until the day she got pregnant in 2012.

“At first I didn’t take all the pills I was prescribed,” she said. “But then I got hurt, so I took a few more, and then I was bit by a brown recluse spider and was prescribed more. Over time, I just took more and more. When I found out I was pregnant, I stopped taking them, and I got really sick.”

She went to the hospital and the nurses told she was going through withdrawal.

“I was dumbfounded,” she said. “I wasn’t a drug addict.”

She wanted to get better and started researching methadone, which she took throughout her second pregnancy. It helped her get her life back, she said, so she could focus on her family and her job.

“When I had my son, he was in the NICU and they had to put him on methadone for a few days,” she recalled. “He wasn’t overly fussy, but he was gaggy and couldn’t eat.”

He’s four years old, now, and Haven said they haven’t experienced any long-term problems.

She worked to wean herself off methadone the past four years and has gone to therapy to deal with her addiction. She’s now pregnant with her third child, another boy due in July, and she’s planning her wedding. Her methadone doses had to be increased, she said, because her doctor wants to make sure she doesn’t go through withdrawal.

She feels guilty that her son possibly will go through the same ordeal her other son suffered.

“But I know (methadone) is safer than painkillers,” she said.

Need help?

— Area Substance Abuse Council residential treatment: (319) 390-4611, asac.us

— Cedar Rapids Comprehensive Treatment Center: (866) 289-0045, cedarrapidsctc.com

— UnityPoint Health-St. Luke’s Hospital chemical dependency program: (319) 363-4429, unitypoint.org

— Mercy Cedar Rapids Sedlacek Treatment Center: (319) 398-6476, mercycare.org

— Prelude Behavioral Services: (319) 351-4357, preludeiowa.org

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Editor’s note:

The Gazette generally does not run stories without first and last names for its primary subjects. But we chose to do so in a

few select instances in the “Heroin’s Hold” series.

It today’s story, The Gazette agreed to leave out Haven and Elle’s last names, in response to their concern about their employment.

To verify the information the women gave us, the reporter for this story also reviewed Iowa Board of Medicine documents regarding Haven’s comments about Dr. Winthrop Risk. Both are patients at the Cedar Rapids Treatment Center and were recommended by the clinic director, who also was interviewed.