Sunday, February 12, 2017

The opioid epidemic reaches the most vulnerable - newborn infants

I recently caught up with my mother, a long-time dietitian who works with low-income women and children at a health department in "The Thumb" of Michigan. "The Thumb" is a region aptly named for its resemblance to the "thumb" of Michigan's mitten-like shape. It is littered with rural communities that are mostly dependent on agriculture.

In our conversation, I asked how her work was going and if there were any new updates. She casually mentioned that she was seeing more and more women and infants who are or were previously addicted to opiates. This comment spurred my interest and this blog post. I wondered, how has the opioid crisis affected women and infants, and how will the Trump administration address these issues?

The opioid epidemic is not a recent development (see other posts about the opioid epidemic here, here, and here). In rural America, the number of people affected by the epidemic is still rising, and this includes the number of drug-dependent newborns who require intensive pediatric services. Doctors frequently prescribe opioids to pregnant mothers to relieve back or abdominal pain (for some startling statistics, see here). The infants of drug-addicted mothers are born with a condition known as neonatal abstinence syndrome (NAS), characterized by symptoms including seizures, breathing challenges, and difficulty feeding.

Although these symptoms can stem from a variety of drugs, a new study by JAMA Pediatrics found that the number of drug-dependent newborns is rising with the rate of maternal opioid use. The JAMA study is also the first to conclude that the number of drug-dependent newborns is accelerating at a higher rate in rural areas when compared to urban areas (increasing almost seven times for infants in rural counties as opposed to four times for infants in urban areas between 2004 and 2013).

The problem is that rural hospitals are not adequately equipped to deal with this increase. As the New York Times recently reported, "rural hospitals that deliver babies have traditionally focused on the lower-risk population in the areas they serve." Now these hospitals are faced with treating mothers with opioid addictions and infants experiencing opioid withdrawals, without enough resources to do so.

Another problem that rural communities face is a lack of access to treatment centers. Some treatment options, like Methadone, must be distributed by a clinic every day, making it difficult for rural residents who must travel long distances. Although Methadone and other similar treatments may be a viable option for pregnant women, a full detox is not, because it can result in dehydration and increase the risk of miscarriage.

In 2016, the Obama administration made some attempts to combat this issue and acknowledged the unique impact of the "opioid crisis" on rural communities.  First, the Comprehensive Addiction and Recovery Act (CARA) was passed by Congress in July of 2016, promising to prioritize funds for addiction recovery programs in rural areas and improve treatment options for rural women. But CARA did not include any secured funding for these programs. Most recently, in December, Congress approved the 21st Century Cures Act, which set aside $1 billion in grants to help states deal with opioid abuse.

Now, with the newly appointed Tom Price to the Department of Health and Human Services (DHHS) and the threat of an Obamacare repeal, discussions are turning towards how the Trump administration will address this problem.

President Trump was remarkably silent about this issue during the campaign, giving only one speech about the epidemic. In this speech, he mostly focused on reducing the supply of drugs - starting with the removal of illegal immigrants, defunding of sanctuary cities, and aggressive prosecution of drug traffickers. Although Trump did address the need for expanded treatment options, it was last on his list.

Price, the conservative surgeon from Georgia, should be familiar with the effects of the opioid epidemic. After all, he formerly represented a wealthy suburban district that is also plagued by the crisis. But while his wife Betty, a Georgia state representative, introduced a bill last year to increase the amount of state needle exchange programs, Price has voted to block U.S. funding for needle exchange programs in the past.

Price is also opposed to Obamacare and very critical of certain provisions, such as mandatory contraceptive coverage for women. If Price fails to enforce or loosens certain health regulations, like coverage for drug addiction treatment, this could make it difficult for individuals to get the care they need.

What does this mean for rural women and infants? Currently, more people have access to addiction treatment as a result of Obamacare, and the 21st Century Cures Act (discussed above) will provide more funding to treatment programs in high-need areas. But as the New York Times reports, if people lose their health insurance, they may also lose access to these treatment programs. DHHS reports that the states likely to see the biggest loss in insurance coverage are also some of those hit hardest by the epidemic, such as New Hampshire, Massachusetts, Ohio, West Virginia and Kentucky.

Finally, the Medicaid expansion offered some financial relief for rural hospitals on the verge of closing, but it is unclear whether they will be able to stay afloat if Obamacare is repealed, making it more difficult for drug-addicted mothers and infants to get the care they need.

4 comments:

Kyle said...

This post weaves together several important threads of the challenges facing rural communities: opioid use/abuse, hospital funding, scarcity of specialty medicine, and access to healthcare services generally. And unfortunately, I fear that the resulting pattern reflects poorly on the Trump Administration's prospects for confronting these issues in a timely and productive manner.

Another concern this post triggers for me relates to the phenomenon of women facing criminal charges after suffering miscarriages. (See, e.g., http://reason.com/archives/2014/05/16/prosecuting-pregnant-women-for-drug-use.) Whatever one thinks of these prosecutions (my initial stance is that they are much likelier to do harm than good), it is clear from this post that the lines between drug abuse and "following doctor's orders" may become more blurred in the years to come, adding to these mothers' woes.

Courtney said...

As Kyle mentioned, this post reminded me not only about the criminal charges pregnant people who have miscarriages face, but also the ramifications of giving birth to a baby with NAS. This is the work that National Advocates for Pregnant Women focuses on. (http://www.advocatesforpregnantwomen.org/). Evidence has now debunked the "crack baby" concern of the 1980s, which focused the lens on urban black women. (https://www.theatlantic.com/national/archive/2013/05/the-myth-of-the-crack-baby/276070/). But new evidence shows that there are many poor, white, drug-using pregnant people in rural areas. (http://jhppl.dukejournals.org/content/38/2/299.full.pdf+html?sid=b0811f36-d4e4-4b51-a830-e175e6eee40c.)

You mentioned the lack of treatment facilities in rural areas, but also there are very few methadone treatment facilities that will even admit a pregnant person. If a pregnant person if using opioids and then finds out they are pregnant, stopping methadone treatment can cause a miscarriage. (http://jezebel.com/5939957/pregnant-women-undergoing-methadone-treatment-caught-in-a-lose-lose-struggle-to-shake-addiction-and-keep-their-kids). However, depending on the social worker, talking to the hospital about your situation could end in prosecution of the termination of your parental rights. Research shows its highly dependent on the social worker's own judgement of the pregnant person if they chose to support their parenting decision or chose to involve CPS or the DAs office. (http://jhppl.dukejournals.org/content/38/2/299.full.pdf+html?sid=b0811f36-d4e4-4b51-a830-e175e6eee40c). I speculate that the rural hospitals may have fewer social workers with less nuanced training on these issues.

Jenna said...

I wonder what impact (if any) the Trump administrations response to this issue will have on the rural individuals who voted for him. While obviously not all of those who voted for Trump are or will be personally affected by a lack of adequate response to the opioid epidemic or the slashing of health care, I am interested to see if there will be any backlash from his base. And, if there is some sort of outcry, will Trump and Congress actually take steps to address these issues, or will they ignore these issues in favor of continuing on with their election promises? For example, instead of voting for more medical funding, will Trump instead continue to push his immigration reform ideas and claim that these changes will help the opioid crisis by supposedly cutting off the suppliers? I guess only time will tell, though I am guessing we will get "the wall" before rural women with potential substance abuse problems will actually be given the help and resources they need.

Wynter K Miller said...

Kyle's point about the blurring of the line "between drug abuse and 'following doctor's orders'" is well stated. One of the most concerning elements of the ongoing opioid epidemic, both in rural and urban America, is the extent to which it was fueled by the medical establishment itself. The statistics you linked to from the New York Times article are especially disturbing because unlike in the 1980's, medical schools have (supposedly) stopped teaching young doctors "that opioids [are] effective treatment for chronic pain, and that treating patients long-term with opioids [is] evidence-based medicine." See http://www.npr.org/sections/health-shots/2016/12/15/505710073/drug-dealer-md-contends-that-well-meaning-docs-drove-the-opioid-epidemic. I think a prescription drug monitoring program would have an impact in rural America, though of course, such a program would only target those patients already abusing prescription drugs. If prescriptions during pregnancy constitute the first instance of opioid use for these women, they would obviously not be helped by a monitoring program. It seems the best strategy for combatting this epidemic is at the source, by modifying prescribing practices. In terms of those already affected, I can only hope the 21st Century Cures funding is allocated and used efficiently.