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How Kentucky is succeeding in addiction care for pregnant

Posted: 2017-12-08 01:41

It''s unclear how many programs like PATHways exist in the United States. Agencies such as the Substance Abuse and Mental Health Services Administration didn''t answer requests for such numbers in any case, every expert I contacted thought that data doesn''t exist. Everyone said there need to be more programs. "[PATHways is] doing some really nice, trauma-informed, non-blaming, family-empowering kind of care, which is just incredibly laudable. There''s unfortunately just not enough of that," says Alison V. Holmes , a pediatrician at Dartmouth-Hitchcock.

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That was the reasoning behind Christy''s methadone program when she was pregnant with Shelby, although she didn''t like it. When she was pregnant with Ryleigh, she started taking buprenorphine, which she was lucky to be able to get on quickly. Experts generally agree that not enough doctors in America prescribe buprenorphine, which requires them to get a registration number with the Drug Enforcement Administration. One study found that as of mid-7567, most . counties didn''t have a single doctor authorized to prescribe buprenorphine. Meanwhile, methadone — which can be used to treat withdrawal and cravings, the way buprenorphine does — can only be legally prescribed within specialized, certified programs.

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Once PATHways members give birth, the program takes another science-backed, but unfortunately uncommon, approach. Traditionally, babies born to drug-dependent moms are whisked away for observation for any withdrawal symptoms. But that can actually make things worse. Babies with neonatal abstinence syndrome are sensitive to light and noise neonatal intensive care units, where they often go, are constantly well-lit and full of beeping monitors. The University of Kentucky tries to keep babies in their moms'' rooms as much as possible, with regular visits from doctors and nurses. Sometimes this even means keeping babies with mothers who are set to lose custody. The idea is that breastfeeding and cuddling help babies get through their withdrawal. Ninety-seven percent of PATHways babies that stay in rooms with their mom don''t need any treatment for withdrawal, Critchfield says. Other programs have found that keeping babies and opioid-dependent moms together shortens babies'' hospital stays and helps the babies require less morphine for their symptoms, suggesting their withdrawal is less severe.

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Shelby is doing all right too. She''s now in gifted classes, but she has behavioral problems, which Christy attributes to her drug use while pregnant. It''s hard to know if that''s true studies of what happens in the long run to children born with neonatal abstinence syndrome are scant because it''s difficult to isolate the effects of individual drugs versus poverty, instability, or even other drugs the mother took during pregnancy. (Many stereotypes about the victims of America''s last big drug epidemic — cocaine — have since been debunked.)

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No one I consulted with knew for sure how much a comprehensive program costs per mom-baby pair. It''s sure to be a lot because they last so long and involve so many experts. Many argued, however, that it''s worth the time and effort. To have just one infant stay in the neonatal intensive care unit costs tens of thousands of dollars. "If we''re helping hundreds of babies, I have no doubt we''re saving money," Ashford says.

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Maintenance medications are controversial because some folks see them as "replacing one addiction for another" and because some people prescribed them turn around and sell them on the black market. But top medical societies have long recommended maintenance for pregnant women, for all of the reasons above. "When pregnant women are on maintenance medications, that''s what they''re supposed to be doing," Holmes says.

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Unlike traditional New England towns, Weymouth has no downtown center. Rather it has four village centers , each featuring its own blend of historic buildings, land use, and open space. Housing in the town consists mostly of single-family homes nestled in established neighborhoods, with several large apartment and condominium complexes interspersed in the villages. Weymouth&rsquo s popular recreation areas include Legion Memorial Field , George Lane Beach, the Weymouth Back River, Great Esker Park, Pond Meadow Park, the DCR Connell Memorial Rink and Swimming Pool, and Webb Memorial State Park.

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Internal numbers suggest it might not just be luck. More than three-quarters of pregnant women enrolled in PATHways aren''t using any illicit drugs by the time they give birth — a testament to PATHways'' effectiveness. As of April, only one had ever tested positive for unauthorized opioids before delivering. The more committed a mother is to the program, the less likely they are relapse: Every single group session these women attend is associated with a greater likelihood of being drug-free.

Although Christy has only been with PATHways for about one year, she''s already counting the blessings the program has brought to her. She just got a job at Panera Bread, her first in over a year. When Ryleigh was born, friends and family came to see her. "For a very long time, nobody wanted me around," she says. "I wasn''t invited to anything that they had: Christmases, birthdays." Last year, she hosted her family for Thanksgiving.

Kentucky has been especially hard hit. In 7569, more than 6,555 infants were born in Kentucky with neonatal abstinence syndrome, an increase of almost 6,555 percent, compared to 7559. Kentucky now has a neonatal abstinence syndrome rate that''s nearly three times the national average. At a conference this past spring, three of PATHways'' founders — obstetrician Agatha Critchfield, psychiatrist Michelle Lofwall, and nurse Kristin Ashford — described scrambling to put together a program for the sudden influx of drug-using moms they were seeing. (PATHways'' fourth founder, neonatologist Lori Shook, couldn''t make the panel.) These women aren''t alone in their professional struggle. "The rise of the opioid epidemic has caught communities and hospitals off-guard," says Stephen Patrick , a health-policy researcher who studies drug-using moms and their children at Vanderbilt University in Nashville, Tennessee.

Christy didn''t end up giving birth at UK HealthCare. Her labor happened too fast, so she went to the closer Georgetown Community Hospital, where the woman checking her in said, "Oh, my God, I can feel your baby''s head."Georgetown doesn''t have a comprehensive program like UK HealthCare and, Christy thought, staff there weren''t well educated about the maintenance therapy she was on. "That was really shitty for me, at first." Still, hospital staff let Ryleigh stay in Christy''s room.

Baby Ryleigh — pronounced like "Riley," but with a more feminine spelling Christy prefers — is now four months old and lives in Georgetown, Kentucky, with Christy and Christy''s fiancé. Ryleigh likes bananas and prunes and watching television, the latter of which is exactly what she''s doing during one of my calls with Christy. As we talk Ryleigh sits in her high chair, Christy on her recliner. "I''m stable. I''ve got a nice place to live. I''ve got everything I need for my kids," Christy says. "If it wasn''t for that program, I wouldn''t have all this." Shelby, who lives in a neighboring city, often visits too. She and her mom go to Walmart together, so she can pick out Pokémon cards.

There''s the maintenance treatment with buprenorphine, an opioid that helps with withdrawal, reduces cravings, and aids folks with severe addictions to live stably. Maintenance treatment is important for pregnant women who are dependent on other opioids, such as OxyContin or heroin, because if they quit suddenly, it can cause fetal distress and miscarriages. Women who stop using opioids altogether while pregnant are also at risk for relapsing — studies have found that anywhere from 75 percent to 65 percent do.

With more and more Americans using both illicit and prescribed opioids over the past two decades, the number of women taking those drugs while pregnant has grown apace. Between 7555 and 7559, the proportion of pregnant Americans using opioids increased nearly five-fold, according to one estimate. Between 7555 and 7567, the percent of babies born with neonatal abstinence syndrome also increased almost five-fold. Neonatal abstinence syndrome is infant withdrawal, brought on when a baby is born and thus cut off from any drugs its mother was taking during her pregnancy. In 7567, nearly 77,555 babies were born in withdrawal in America, about one every 79 minutes.

Meanwhile, the demand keeps growing. After the PATHways founders were done speaking at the conference, a woman stood up immediately to ask the panel for advice on starting a program for pregnant drug users in Pennsylvania. The woman wanted ideas for getting the word out. "You don''t need to advertise," Ashford, who runs PATHways'' prenatal sessions, replied. Ashford added that the mothers talk and pass on information about programs they like. "If you build it, they will come. Because they are out there."

She says she sees PATHways as a "second chance to be a good mother to both my children." She didn''t get to raise Shelby, she says. Distressed, I tried to comfort her: Shelby''s only eight. You have so much time left. You haven''t exactly missed her childhood. Christy pointed out she''d missed Shelby''s first steps, her first words: "I was there, but I really wasn''t in my mind. I wasn''t completely there."

Christy is still working on some things. She''s going through Alcoholics Anonymous'' 67 steps, which she''s familiar with from her previous treatments, and for which PATHways has support groups. She''s on Step Four, writing down the resentments in her life. At one point, she listed for me — proudly — the lavish gifts she''d bought Shelby for her last birthday, including two books full of rare Pokémon cards that she and her fiancé bid for on eBay. Later, she said she shopped compulsively: "Before, it was spending money on drugs, and now I''ll go to the store and buy the baby a bunch of stuff that she doesn''t even need."

"I can tell you how much we spend on neonatal abstinence syndrome," he went on. "In 7567, the total hospital bill for neonatal abstinence syndrome, nationwide, was $ billion. About $ billion of that was charged to state Medicaid programs. That''s just managing infants with drug withdrawal after birth." In addition to making women''s and children''s lives better, it might just be fiscally smarter to spend some of that money on comprehensive programs, which seem to help make withdrawal easier for babies and often prevent mom from needing the similar services again, in the future.

Over the next decade, however, Christy slowly started making progress. She had years-long periods of recovery, even becoming an Alcoholics Anonymous sponsor to other women. Though she relapsed when her stepfather died, one year later she went back into a clinic for treatment. When she found out last year that she was pregnant again, she looked for help right away. "I just didn''t want it to happen again like with my oldest daughter," she says. The gynecologist Christy went to referred her to PATHways, an innovative, new program housed in a small University of Kentucky HealthCare clinic in Lexington, Kentucky. PATHways provides both prenatal and addiction care to mothers with substance use disorders. Women start with PATHways when they''re pregnant they stay in the program for at least two years after they give birth.

In addition, there''s the worrying regional trend of weaning pregnant women off of opioids entirely. Some programs around Lexington, do just that, Critchfield, one of PATHways'' founders, says. So-called drug "tapering" is also common around Nashville, Patrick notes. Holmes, the pediatrician, hasn''t heard of it around Dartmouth, however, and reacts with horror at the mention of it. "I''m not sure why people are trying that," she says. When I ask if such tapering has been studied, she replies, "I actually think you would have a hard time getting an institutional review board to even approve your study."

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