Hospitals adapt as opioid epidemic hits infant victims

At one time, babies withdrawing from drugs were a rarity, except in the inner city. But now from Boston to Springfield, from Plymouth to Worcester, they are a regular presence at birthing hospitals large and small, as the state’s opioid epidemic cascades down to the next generation.

Nationwide, the number of newborns treated for drug withdrawal increased nearly fivefold between 2000 and 2012, according to a study this year in the Journal of Perinatology. The study estimated the annual cost of their care — days to weeks in the hospital — at $1.5 billion, more than 80 percent paid by Medicaid.

In Massachusetts, where the opioid-abuse epidemic has hit particularly hard, hospital data suggest that the rate of drug-dependent newborns is two to three times the national average.

Charlie’s illness was a consequence not of neglect, but of diligence. Years before his birth, Frigon had been addicted to painkillers. In recovery, maintenance drugs successfully controlled her addiction. She followed her doctor’s advice to keep taking a steady dose during her pregnancy, even though the baby, inevitably, would take the drug along with her.

Some 20 to 40 percent of babies exposed to drugs in the womb are born without any symptoms. But the rest go into withdrawal, experiencing what doctors call neonatal abstinence syndrome, or NAS: irritability, tight muscles, excessive crying, low-grade fevers, difficulty feeding, tremors, watery stools, sweating, and sneezing.

Charlie would need medication — small doses of morphine — and then he would need to wean off morphine. But, doctors say, what he most needed is what Frigon provided day in and day out: cuddling, breast milk, love.

“A lot of these moms are trying really hard to do what’s right,” said Dr. Munish Gupta, a newborn medicine specialist at Beth Israel Deaconess Medical Center in Boston. “They’re in recovery from a terrible illness.” For many, that illness is best treated with medications such as methadone and buprenorphine. That’s why, Gupta said, “We’re not going to get rid of NAS for a long time.”

The road to addiction, Frigon said, started with a prescription: Percocet to relieve pain from wisdom-teeth removal. She was 16, and for the first time she felt confident and calm. She now believes that without knowing it, she was medicating an anxiety disorder.

At a gathering of high school friends in suburban Millbury, someone took out one tiny OxyContin pill, crushed it and passed it around to sniff. Frigon’s life would never be the same.

“By two years later, I needed two 80-milligram Oxy just to go to work,” she said. For the next few years, she lived in pursuit of pills, at one point sleeping in her car.

When Frigon became pregnant with her first child eight years ago, her mother went to court to have her committed to a drug treatment facility, where she started on methadone. The day she gave birth to William at UMass Memorial, she felt transformed, filled with a sense of purpose — and she says she has not misused drugs since. William, she says, “saved my life.”

It was 2007, and in those days, drug-exposed babies were given a diluted tincture of opium — which Frigon said left William “conked out,” so she never witnessed any withdrawal symptoms.

William’s doctors had been winging it. With limited experience caring for these babies, every hospital had its own way of doing things, said Dr. Alan P. Picarillo, chief of newborn medicine at UMass Memorial. Some hospitals didn’t even have written policies or procedures.

The opium treatment approach was abandoned a year or two after William left the hospital. Further changes occurred after 10 Massachusetts hospitals that treat the highest-risk newborns launched a joint effort, in 2013, to improve the care of drug-exposed babies, ultimately drawing 42 hospitals into the project. The hospitals are working on setting policies and standards and better engaging the parents.

But they have few hard facts to guide them, said Dr. Jonathan M. Davis, chief of newborn medicine at the Floating Hospital for Children at Tufts Medical Center. “People aren’t sure about the best treatments in the mothers. They’re not sure about the best treatment in the baby. And everybody does something different,” he said. Davis is leading a nationwide study comparing treatments, but answers are years away.

Meanwhile, the hospital collaborative has reduced the length of hospital stays and increased breast-feeding. (Doctors believe the benefits of breast-feeding outweigh any hazards from the traces of maintenance drugs that may get into breast milk.) But the biggest improvement, Gupta said, has been changing attitudes by teaching the staff that addiction is a chronic illness.

Before she became pregnant with Charlie, Frigon had switched from methadone to another drug, buprenorphine, to silence her cravings. She was hopeful that with the new drug, Charlie would not go into withdrawal as William had. Although devastated that Charlie needed to be admitted, she had a different experience the second time. She was able to stay with the baby overnight, breast-feed, and soothe him when he got fussy.

She was lucky: Not every hospital has space for parents to stay. Women often have trouble getting transportation to the hospital and have other obligations — jobs, other children, group therapy required as part of their addiction treatment.

“The women that are going through this have no allies,” Frigon said. “No one thinks they deserve their kids. The thing people need to know is: Nobody wants to be like this.”

On average, a baby withdrawing from drugs stays in the hospital about 16 days, at a cost of $93,000. But Charlie had trouble weaning off the morphine used to ease his symptoms, and needed 31 days.

“I’m still ashamed that I put him through that,” Frigon said. “The big thing about addicts that nobody gets, your guilt never goes away.”

But how will he do over time? William, her 7-year-old, just finished first grade with high marks in reading and math, Frigon said. And Charlie is a cuddly 4-month-old who looks the picture of health.

Barry M. Lester, director of the Brown University Center for the Study of Children at Risk, said that even though methadone- and heroin-exposed babies have been seen since the 1970s, there are no good studies of the long-term effects.

“Some studies show impairment in IQ, cognition, behavior problems, increased anxiety,” he said. “But there are also studies that find no differences.” And none of the studies adequately accounts for the myriad other factors that affect a child’s development.

“Environmental factors are probably just as powerful as prenatal drug exposure,” Lester said. “What these drugs really do is they predispose a baby to be on the vulnerable side. . . . If brought up in a good environment, chances are the baby is going to be fine.”

Michelle Frigon appears equipped to provide just such an environment. Her pregnancy with Charlie, while not planned, was welcome. She remains close to his father, and they plan to marry. Her parents have provided shelter and support for years. In treatment, she met women who had been through detox multiple times, whose veins were destroyed from injecting drugs, who had nowhere to turn for support. “I’m so lucky,” she says.

The Department of Children and Families assesses the family situation when a baby is born exposed to drugs. Frigon said the agency interviewed Charlie’s doctors and relatives, and hasn’t been involved since; DCF doesn’t comment on individual cases.

But most mothers of drug-exposed babies require more attention from the agency. Some are women in maintenance treatment, such as Frigon; others are active users of street drugs or women who took painkillers, often prescribed.

Between March 1, 2014, and March 31, 2015, the agency responded to 2,265 cases of children born exposed to drugs. In a quarter of those, DCF staff concluded the child would be safe at home and did not require additional services.

But DCF had concerns about the rest — and in 490 cases, the child was placed in foster care, a higher rate of placements than for other children whom the agency is involved with.

In cases in which DCF remains involved but the baby stays at home, the agency arranges for services, stays in touch with treatment providers and others who have contact with the family, and monitors the situation closely, according to Amy Kershaw, DCF’s assistant commissioner for policy and practice. “The research is very clear that kids do better living at home,” Kershaw said. “Most of our work is trying to keep kids safely at home.”

Although the agency has always worked with families affected by substance misuse, the current opioid crisis is uniquely challenging, Kershaw said. “We are feeling the impact across the system,” she said, with increasing numbers of families needing services from DCF and increasing cases of children being removed from the home.

Jane Shropshire, a clinical nurse specialist with Spectrum Health Systems, an addiction treatment provider, said not all pregnant addicts are ready to start recovery. “It’s a challenge to work with some of them,” she said. “The thing that makes it the most difficult is when they don’t embrace recovery.”

But she adds: “A lot of these women are very good mothers. They just happen to have a horrible disease.”

Abigail Haskins has that disease. It started with prescribed painkillers in her teens and progressed to heroin.

But two years ago, she went on methadone and hasn’t looked back. Two months after starting treatment, she became pregnant.

Haskins, who lives in Clinton, north of Worcester, recalls standing in line at a methadone clinic while pregnant. Someone behind her muttered, “That’s so selfish. If I was pregnant, I wouldn’t be here.”

“People judge you all the time,” she said. “People said, ‘Get off,’ like it’s that easy. . . . I would have stopped, but I talked to doctors and they said that was a horrible idea.”

The American College of Obstetricians and Gynecologists advises against withdrawing from drugs during pregnancy.

“Withdrawal is very physically taxing on the mom,” said Dr. Jessica L. Young, an obstetrician-gynecologist who runs a clinic for drug-dependent pregnant women at Vanderbilt University Medical Center in Tennessee. Withdrawal, she said, can lead to uterine cramping, high blood pressure, rapid heartbeat, and increased blood flow to the placenta, conditions that can result in miscarriage or preterm labor.

And stopping methadone, even gradually, is also considered too risky, because the woman could relapse into illicit drug use, which is far worse for the baby.

Dr. Kelley A. Saia, director of Boston Medical Center’s Project RESPECT, a treatment program for pregnant women struggling with addiction, said most mothers want to get off medication because they don’t want their babies to go into withdrawal, but she works hard to persuade them to continue. Among those who stop their medication, “99 percent of them relapse before delivery,” she said. Then, they’re more likely to be taking more than one drug and exposing babies to ever-changing doses.

Haskins stayed with her methadone treatment. When her baby was born in April 2013, he went into withdrawal. She visited him every day at UMass Memorial for several weeks. She hated seeing him go through that, hated not being able to take him home.

Today, Ayden is a lively 2-year-old, who, his mother said, came out with flying colors on a recent developmental evaluation.

Haskins said she never thinks about using heroin and does not crave it. Besides, she said, she’d never do anything to jeopardize Ayden: “He is my life. He just makes me smile every day.”

Felice J. Freyer can be reached at felice.freyer@globe.com. Follow her on Twitter @felicejfreyer