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 (full disclosure: Hart and I are currently collaborating on a book), who was not associated with the research. “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 neurodevelopmental 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.