The rate of babies born to mothers who use
prescription painkillers during pregnancy has risen sharply over the last
decade. Though the long-term effects of such drug exposure are uncertain, true
harm can come of labeling these babies as "addicts" at birth.
The number of
babies born suffering from withdrawal symptoms due to their mothers’ use of
prescription painkillers during pregnancy more than tripled between 2000 and
2009, according to a new study published in the Journal of the American
Medical Association. The authors estimate that one infant is born every
hour in the U.S. with symptoms of opioid withdrawal, accounting for some 13,500
babies each year. Over the same time period, the number of women using opioid
pain relievers like Oxycontin during pregnancy nearly quintupled and related
health-care costs — particularly the care of drug-exposed infants in neonatal
intensive wards — rose to $720 million annually, from $190 million.
“This serves as a
reminder that this is really a public health emergency,” lead author Dr.
Stephen Patrick of the University of Michigan told JAMA Report. However,
the study did not determine what proportion of these opioid-exposed children
were born to mothers who were taking painkillers as prescribed by their doctors
for chronic pain or other conditions and what proportion were born to addicted
mothers who were misusing the drugs.
“This study raises
more questions than it answered,” says Carl Hart, associate professor of
psychology at Columbia University “For one, it failed to take into account that
there are many women who are prescribed opioids for medical reasons and these
women are following their physicians’ orders and behaving in the way that
society wants them to behave. There’s no distinction made between these women
and those who are using opioids illicitly.”
Prescription drug misuse
has risen in tandem with a sharp increase in legitimate prescriptions for pain
medication, owing to a better recognition of the high prevalence of severe
chronic pain. Both trends are likely to have affected painkiller use by
pregnant women, but it is difficult to say exactly how many women use the drugs
legitimately and how many do so without a prescription. For the study,
researchers mined a database containing information on millions hospital
discharges following births in thousands of hospitals in 44 states between 2000
and 2009. They found that infant opioid withdrawal appears to affect poor
children disproportionately: 78% of women who gave birth to children who
suffered withdrawal symptoms were on Medicaid, compared with 46% of those who
had healthy babies.
About 60% to 80% of
babies exposed to chronic opioid use in utero will develop what doctors call
neonatal abstinence syndrome, which is similar to the symptoms that plague
adults going through withdrawal.
“Common symptoms that babies exhibit after
they’re born are things like irritability, difficulty with feeding [and]
difficulty breathing,” says Patrick. Infants exposed to opioids in utero also
tend to have a hard time sleeping and are nearly three times more likely to
have low birthweight, which has been linked to developmental problems. Withdrawal
symptoms do not seem to do long term damage after birth. Since withdrawal is
caused by an abrupt decline in the dose of drug in the body, hospitals
typically treat affected babies with low doses of methadone, morphine or other
opioids that are similar to what their mothers were taking. These drugs are
then tapered slowly to avoid, or at least minimize, withdrawal symptoms.
Mothers can also
help their babies by nursing while receiving maintenance drugs after delivery,
since they can pass some of the drug onto their infants through breast milk. Indeed,
the best treatment for women who become pregnant while dependent on opioids, or
who develop drug dependence or addiction during pregnancy, is not to attempt
immediate abstinence. That may actually harm the fetus and carries a high risk
for relapse that could cause further damage.
Instead, doctors
recommend maintaining women on a stable dose of methadone or buprenorphine,
which controls their opioid exposure and doesn’t leave the baby at risk for
damage from abrupt changes in drug levels. “The consequence of hysteria [about
the dangers of fetal exposure] is that you can have women stop using abruptly
and we know that can do more damage to the child,” says Hart.
Far less is known
about the long-term outcomes of drug exposure in utero. Early studies showed
minimal or no negative effects from prenatal exposure to methadone in children
of women who were maintained on the drug. Later research suggested, however,
that there may be some increased risk for developmental disorders like ADHD and
cognitive problems.
Similar concerns
arose in the 1980s when babies born to crack-cocaine-addicted mothers were
thought to be doomed to have severe disabilities or even to become vicious
criminals. In 1989, syndicated Washington Post columnist — and M.D. —
Charles Krauthammer went so far as to write: “A cohort of babies is now being
born whose future is closed to them from day one. Theirs will be a life of
certain suffering, of probable deviance, of permanent inferiority.” He further
claimed that such children would have “permanent brain damage” of a type that
couldn’t even be helped by early intervention programs like Head Start. Research never
supported such claims. As it turns out, exposure to crack cocaine in the womb
isn’t good for babies, but it’s not any more harmful than cigarette smoke. Both
can increase the risk of stillbirth and preterm birth and cause measurable
neuro-developmental problems — but that’s a far cry from having a closed future
at birth. (The only recreational drug known to limit a child’s potential
irreversibly during pregnancy is alcohol.)
More important than
drug exposure is the environment that babies are born into. Babies exposed to
cocaine before birth are much more likely to develop later problems in school
or at work if they grow up with domestic violence or child abuse than if they
are in stable homes. They benefit tremendously from early intervention
programs. “My major concern
is that we’ve already been here with crack and we know what that kind of stigma
can do,” says Hart. “The stigma can be worse than the effects of the drug
itself.”
We also know from
the crack epidemic what doesn’t help these vulnerable babies: removing their
mothers without providing addiction treatment, jailing mothers while pregnant,
prosecuting them for exposing their babies to the drugs or giving up on them
without even trying. Moreover, research shows that using stigmatizing labels
like “crack baby” can do real harm: first by encouraging others to view such
children with bias — for example, wrongly characterizing normal behavior as
defiant or manipulative — and secondly, by making the children themselves
believe that they are permanently defective.
Although infants
are clearly being exposed to opioids in utero at a worrying rate, the absolute
numbers are low. In national surveys, about 1% of pregnant women — or 21,000
mothers-to-be — acknowledge that they misuse prescription opioids, although
rates for pregnant teens are probably higher. The trends are
worrying, but if we want to help these vulnerable children, we would be wise to
leave their care to doctors, scientists and epidemiologists — not to police or
politicians.
Health Land
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