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.