For Your Health

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Colorado grapples with 80 percent jump in newborns going through opioid withdrawal

Pueblo hospital’s number of drug-addicted babies makes others “shudder.”

She was born early and tiny, at 5 pounds, 11 ounces, with chunky, pink cheeks and a dash of brown hair. Baby Isabella, 2 weeks old and swaddled in a hospital blanket, also was born addicted to opioids.

The preemie — who arrived Nov. 2 in Colorado Springs, about five weeks early — was one of six babies recently in the neonatal intensive care unit at UCHealth Memorial Hospital going through opioid withdrawals because of their mothers’ drug use.

The rise in Colorado newborns addicted to opioids has alarmed physicians and child advocates, jumping 83 percent from 2010 to 2015. The state’s rate, according to the Colorado health department, climbed from 2 births out of 1,000 to 3.6 births in that five-year period.

In some parts of Colorado, the rate is much higher. At Parkview Medical Center in Pueblo, the city’s safety-net hospital that sees many Medicaid patients, the rate of newborns addicted to opioids skyrocketed from 0.7 per 1,000 in 2010 to 20.8 in 2012. The rate at Parkview now hovers around 10, and doctors have noted a shift from prescription drugs such as Oxycontin to street drugs, mainly heroin, in recent years.

For Isabella, the symptoms of neonatal abstinence syndrome — when newborns go through opioid withdrawal — were mild. She came close to needing methadone, but doctors, nurses and her parents were able to get Isabella through the worst of it with cuddling and skin-to-skin contact. The infant has had an elevated temperature, loose stools and trouble latching on to drink milk.

The reason Isabella didn’t suffer the most severe symptoms of the syndrome — tremors, seizures, inconsolable crying, sweating and inability to sleep — was that her mother had stopped using heroin and was in treatment during pregnancy, taking a daily opioid pill to stop the cravings.

“There we go, sugar buns,” said Isabella’s mother, Rachel, while pulsing a finger into her baby’s cheek to try to get the infant to suck a bottle. Rachel, 30, didn’t want her last name used in this story because she is trying to put her life back together after years of addiction to Oxycontin, Percocet and heroin.

Rachel and her husband lost their house. He was kicked out of the Army. Their son — 3 years old at the time — was placed in foster care, and she nearly died of respiratory failure due to heroin use before they reached “the bottom” and went to rehab about a year ago.

Rachel’s addiction was too strong, the dope sickness too severe, for her to give up street drugs without the doctor-prescribed daily opioid pill. She was forthright with her obstetrician from the start.

“Your mama-bear instincts come out and you care more about your child than about being embarrassed,” Rachel said.

The increase in opioid-addicted babies in Colorado has resulted in an unprecedented collaboration between hospitals, medical professionals and child-welfare departments. So far, a Substance Exposed Newborns Steering Committee has helped pass a state law that stipulates pregnant women can tell their doctors about drug use without fear of criminal prosecution.

The group is working toward consistency in screening among prenatal clinics and hospitals throughout the state. Every pregnant woman should answer the same questions, no matter their demographic, and every labor and delivery department should adopt a standardized screening that would determine whether to test a baby’s urine or umbilical cord for drug exposure, said Jade Woodard, co-chair of the steering committee.

“Pregnant women aren’t using because it’s fun,” Woodard said. “It’s not a choice at that point. They want to stop, but the addiction is too strong and they don’t see a way out.”

Although some hospitals recently have redefined policies, the “screening” at others is a “conversation based on what you look like, what you smell like,” said Woodard, executive director of Illuminate Colorado, a nonprofit focused on child abuse. Without protocol, a straightforward question about drug use could sound more like a joke, as in “You’re not using meth are you?”

Some hospitals and clinics don’t require a parent’s permission to test a baby for drugs, often through umbilical cord analysis that can determine at least the last trimester of exposure. Others won’t test unless a parent agrees.

The danger in not identifying drug-addicted babies before they leave the hospital is that a mother using drugs goes home without intervention or support and struggles to care for a fussy infant who won’t calm down long enough to eat or sleep. Symptoms of neonatal abstinence syndrome often do not appear until a newborn is 5 days old, and most babies leave the hospital after two days.

At Parkview in Pueblo, Dr. Pastora Garcia-Jones treats opioid-addicted babies daily, often with methadone and morphine. Over the past two years, she pushed for a more robust hospital screening and testing policy, and for a social worker dedicated to the nursery. No parental permission is required at Parkview to test a baby for drugs, and the hospital tests based on risk factors such as no prenatal care, placental abruption and undernourishment.

The six-bed neonatal intensive care unit is so crowded, usually with opioid-addicted babies, that Parkview is adding four beds. Other hospitals in the state “shudder at our numbers,” said Garcia-Jones, who also treats opioid-addicted babies in Colorado Springs, including Isabella.

Ground-breaking research from a Connecticut pediatrician revolutionized the way some Colorado hospitals treat opioid-addicted newborns. Instead of weaning babies by automatically dosing them with methadone or morphine, advises Dr. Matthew Grossman at Yale-New Haven Children’s Hospital, doctors should attempt to treat babies by breastfeeding on demand and cuddling.

Infants need opiates only if they can’t eat more than 1 ounce, can’t sleep for more than one hour and can’t be consoled in 10 minutes, according to Grossman’s research, published this year.

At least 10 hospitals in Colorado are adopting the protocol, including University of Colorado Hospital in Aurora. The Yale paper was a “game-changer,” said Dr. Susan Hwang, a neonatologist at University and Children’s Hospital Colorado.

University also revamped prenatal screening in January, asking every pregnant woman the same questions during pregnancy and delivery and recording the answers in electronic medical records. The screening isn’t just for the babies: The No. 1 cause of death for pregnant women and new mothers in Colorado is drug overdose, and most of those deaths happen within the first month after giving birth.

“Part of our responsibility is to identify that there is a mother in need,” said Dr. Erica Wymore, a neonatologist at Children’s and University hospitals. “We, as providers, need to take more responsibility.”

The opioid epidemic is reflected, too, in the number of calls to child welfare departments in Colorado to report children exposed to substance abuse. Such calls spiked in 2015.

Singling out the calls regarding newborns, defined as babies younger than a month, statewide referrals for drug exposure rose from 206 in 2012 to 380 in 2015, dropping to 314 in 2016, according to the Colorado Department of Human Services. The numbers include babies exposed to heroin, prescription painkillers, other opioids and marijuana.

State child abuse and neglect laws require a doctor or hospital to report any positive drug test in an infant. A physician who finds that a pregnant woman is using drugs is not required to report that to child welfare officials unless the woman has other children who are in danger of neglect.

But Paige Rosemond, associate director of programs for the state Office of Children, Youth and Families, said doctors should let child welfare officials determine whether children are in danger. She battles the misconception that caseworkers will arrive and immediately take a child.

The child welfare department has moved from a “punitive approach to a holistic one,” where the first goal is to keep even a drug-addicted newborn and mother together, Rosemond said.

Caseworkers can set up in-home nurses and connect a mother to drug treatment, preferably at a “co-placement” center where mother and baby can share a room. Colorado, though, has few co-placement beds available, Rosemond and others said.

The fact that many opioids are legal and prescribed by doctors and that marijuana has been legalized has created gray area for health professionals trying to help drug-exposed babies, said Dr. Kathryn Wells, medical director of the Denver Health Clinic at the Family Crisis Center. It’s not the same as the “crack baby” era of the 1980s or the cocaine and methaphetamine crises of the 1990s.

“We are now shifting the conversation to this being a health-care issue as opposed to a moral failing or a criminal issue,” she said. “We can look at people in a judgmental way, or we can start to understand that the infants and the families who are affected are not just ‘those people over there.'”

Rachel, baby Isabella’s mom, was in college in 2008 when she had surgery to repair her ACL because of a skiing injury. She was prescribed Oxycontin, Percocet and morphine.

She left her parents in Colorado and returned to the University of Central Florida, feeling “cut off” from the painkillers, sick with withdrawal and unable to find a doctor to prescribe her more. She started buying them on the streets of Orlando. And soon, because it was easier to find, Rachel turned to heroin.

After she married, Rachel and her husband used drugs together, although they managed to stay sober for a few years when the Army sent them to Germany. The day they moved to Colorado Springs in 2014, where her husband was stationed at Fort Carson, they met a person who offered Percocet.

They took it.

Within about a year, Rachel said, they went from a middle-class lifestyle to homeless and living in motels or a car. When her husband was pulled over with drugs in the car, along with their 3-year-old son, the boy was placed in foster care.

Their heroin use got worse. “You are depressed. No hope. Trying to numb the pain,” Rachel said as she rocked Isabella in their neonatal intensive care unit room.

Rachel lost her job as a home-health nurse. Her husband left the Army. As they bounced from motel to motel, Rachel came down with severe bronchitis. Fluid filled her lungs and her respiratory system failed, a side effect of heroin use.

When she came out of a months-long coma, she entered rehab last November. Rachel and her husband now visit the Colorado Treatment Center each morning to take a pill called Subutex, an opioid that has curbed her desire for heroin. Their son has returned home, after about a year in foster care.

Rachel says pregnant women who are using drugs want to stop, but they don’t know they are strong enough.

“The more honest I was, the more support I had,” she said. “When I was hiding it and denying it, I had a lot less respect.

“I’m not ashamed. People make mistakes. Mine was kinda crazy, but own it and move on.”

http://www.denverpost.com/2017/11/29/colorado-newborn-opioid-withdrawal/?obref=obinsite