July 21Dr. Robert DiGiuseppe must treat the babies whose first days of life are marked by excruciating pain. They are inconsolable, cry and sweat excessively, have diarrhea, stiff limbs, vomiting and sometimes seizures.
The cause of their ailments: prescription opiates their mothers took during pregnancy.
"You feel sorry for these babies because they're struggling, they're suffering," DiGiuseppe said one recent afternoon at New Hanover Regional Medical Center, where he practices in the Neonatal Intensive Care Unit. "They're absolutely miserable."
America's prescription drug abuse epidemic has caused a spike in the number of addicted mothers and newborns experiencing withdrawal symptoms delivering in maternity wards across the country. While there is no universally accepted standard of care for their offspring, the rise fueled efforts to evaluate treatment practices and sharpened calls for more resources to combat addiction.
At New Hanover Regional Medical Center, the number of newborns treated or monitored for drug withdrawal shot up 119 percent in three years, from 31 in 2009 to 68 in 2012. Many must be painstakingly weaned off whatever their mother used, extending hospital stays and driving up medical costs.
The phenomenon is by no means Wilmington's alone. A study published last year in the Journal of the American Medical Association found the number of babies that underwent withdrawal, a condition known as neonatal abstinence syndrome, tripled from 2000 to 2009, when 13,539 were born, or nearly two every hour.
Treatment costs increased 35.5 percent over that same period, from $39,400 for each withdrawal case to $53,400. In 2009, 77.6 percent of those costs were charged to Medicaid, according to the study.
"It is a huge financial drain on the medical system," DiGiuseppe said.
There are no national statistics to document the scale of the problem as it stands today, but interviews with researchers, doctors and drug treatment specialists suggest it continues to escalate.
"The worrisome thing is that the prevalence of the diagnosis has increased fairly dramatically," said Dr. Mark Hudak, who heads the University of Florida's Department of Pediatrics and authored the American Academy of Pediatrics' most recent guidelines for treating the syndrome, released last year.
Physicians generally advise mothers who have been taking prescription opiates medications based on opium or its derivatives for extended time periods to continue during pregnancy because quitting cold turkey may cause her to withdraw, increasing the risk for miscarriage and pre-term birth, experts say.
Pregnant addicts on methadone treatment, a time-tested opiate medication that staves off withdrawal and reduces cravings, are also instructed to stick to their regimen, not only because stopping may harm the fetus but because it may also drive her to relapse and use street drugs, experts say.
"It's a complex problem that's going to take a complex solution," said Dr. Stephen Patrick, who lead last year's study published by the American Medical Association while at the University of Michigan.
Researchers have looked at outpatient treatment as a means of driving down costs, with some literature suggesting at-home care can be successful if the family is properly screened. But critics call it a risk.
"One of the problems in North Carolina is that with the pressure to get people out of the hospitals, we know of instances where people with serious, untreated opiate addiction have been sent home with bottles of liquid narcotics to treat neonatal abstinence in their babies," said Dr. John Thorp, who founded the University of North Carolina's Horizons Program, which treats children exposed to drugs before birth. "To give them something they're addicted to is the craziest thing I can think of doing. It would be like the fire department giving out molotov cocktails."
There exists little definitive research on whether neonatal abstinence syndrome harms health or development outcomes, and researchers seem divided on whether opiate exposure in the womb causes long-term consequences.
"Some studies show issues with learning and some studies show nothing at all," said Patrick, who is now at Vanderbilt University and working on research to determine best practices for neonatal care. "If you look at the data that's out there, there might be long-term implications, there might be none. It's really unclear."
A study by the Centers for Disease Control and Prevention discovered that babies whose mothers took legally prescribed painkillers during pregnancy had a slightly higher risk of birth defects, including congenital heart defects, glaucoma and spina bifida.
"The good news on this is that if there is a long-term effect related to prenatal opioid exposure and post-natal treatment, it is relatively small," Hudak said. "It's not like these children are neurologically devastated."
More worrisome are the consequences of growing up in a house where addiction is present. "This is a family disease and the public should be extraordinarily concerned," Thorp said.
Treatment approaches differ across hospitals, but doctors generally rely on either methadone or morphine to slowly wean the babies off while keeping their discomfort in check.
Prescription vs. abuse
Most cases of neonatal abstinence syndrome at New Hanover Regional involve mothers prescribed pain medication such as Percocet and Lortab by their physicians, but even taking opiates in doctor-recommended doses can cause newborns to withdraw.
"They don't realize that that's a possibility that their baby can withdraw because my doctor prescribed this to me. Nobody is going to prescribe me anything that's going to hurt my baby," DiGiuseppe said
Sometimes withdrawal symptoms will not set in for several days. So if doctors know the mother used opiates, they will keep the baby at the hospital under observation.
"We discuss this with clients so they are ready for this; it's expected," said Ruth Trammel, a clinical supervisor at Coastal Horizons, a Wilmington-based drug treatment facility. She is currently treating six pregnant addicts, a group which meets once a month with a nurse from the Neonatal Intensive Care Unit to discuss motherhood and pregnancy issues.
Mothers using street drugs are less likely to admit as much to their doctors, and so they sometimes return to the hospital when their baby starts showing symptoms, experts say. Some doctors will perform drug screens on pregnant patients, but there are legal and ethical quandaries to that approach.
Few doctors even treat pregnant opiate addicts because of the risks involved.
People "want to act like they don't exist because there's so much contempt for pregnant people who use and abuse substances," Thorp said, noting that some pregnant addicts try to hide their disease for fear of social services. "Everybody just hasn't come to grips with the 5 to 10 percent of the world that has the disease of addiction and needs treatment, and that includes reproductive-age women, and reproductive-age women get pregnant."
Brian Freskos: 343-2327
On Twitter: @BrianFreskos
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