The babies cry inconsolably in high pitches, while tremors make their limbs quiver like vibrating strings. Their open mouths drift, unable to find their bottles, until they do, and then they suck so much they throw up. Nurses wrap them tightly in blankets to keep them from hurting themselves as their muscles tighten and jerk in spasms.
In Sarasota Memorial's intensive care nursery, these infants are now up to half the population at times. They are born addicted to painkillers or the painkiller substitute methadone -- collateral damage in a national epidemic of prescription drug abuse.
"They're trying to come out of their skin," said Judy Cavallaro, a nurse who oversees the hospital's nursery, where the withdrawing babies are sometimes first spotted and then sent to intensive care. "It's traumatic for everyone."
Even as overall births statewide are on the decline, the number of newborns going through withdrawal from narcotics such as Oxycontin has increased 160 percent in Florida since 2005. Many doctors suspect the number of addicted babies may be even higher, because drug testing for pregnant women and newborns is not mandatory, and some babies do not begin to show withdrawal symptoms until after they leave the hospital.
There are now far more babies born addicted to prescription drugs than to crack cocaine. When Sarasota Memorial made painkillers the topic of its annual regional conference on at-risk infants this spring, there was record attendance.
Not only is the withdrawal physically painful, but treatment can be difficult for doctors and nurses struggling to become familiar with the problem, and the costs are high, both in dollars and emotion. Each child's stay in neonatal intensive care costs between $15,000 and $20,000, a bill often delivered to taxpayers through Medicaid.
The human toll is far more poignant: If newborns are not properly weaned from the drug, getting an increasingly smaller amount each day, the addiction can kill them. Deaths are sometimes disguised as seizures or Sudden Infant Death Syndrome.
The worry continues even after a successful withdrawal. Unlike with babies born of the last big drug epidemic, cocaine, little research exists on the long-term effects of painkillers on children exposed before birth.
"We may well need special programs for these children when they get to school; we don't know," said Tony Napolitano, a neonatologist at both Sarasota Memorial Hospital and All Children's Hospital in St. Petersburg. "It's like a new social disease we have. It's very scary."
One mother's story
When Danielle Rose, a 26-year-old with wavy hair who works as a waitress, found out she was pregnant, she had been abusing prescriptions and other drugs for years.
Using body scans showing she had a bulged disc from an old car accident as proof she had back pain, she lied to get doctors to prescribe painkillers including Lortab, Oxycodone and Roxycodone, her medical records show.
"I told them it hurt and I needed three or four Oxys a day, plus muscle relaxers, to make it bearable," said Rose, who has since been through a Christian rehabilitation program and views telling her story as a way to help others.
"When I got pregnant I knew I should stop but I couldn't," Rose said. "I was two months pregnant, then three months, then five months and I was still getting high every day. At that point I needed them to feel normal."
Gaps in Florida law make it easy to get painkillers, even for pregnant women. For pregnant women, narcotics present a problem that other drugs, such as cocaine, do not. Once pregnant, even women who tell their doctors they are using drugs cannot stop taking painkillers or a methadone substitute for them, because of the risk that it will cause a miscarriage.
Doctors have to keep prescribing drugs like Oxycodone or Roxycodone, or send pregnant patients to clinics where they can receive daily doses of methadone, a controversial practice but a legal one meant to keep women from abusing prescriptions on the street or dying from an overdose.
Methadone, itself an opiate, also causes withdrawal in babies.
Ideally, if pregnant women are found using painkillers in the early weeks of pregnancy, they can be weaned off without complications. But the window is small, and "It is so addictive people usually can't get off the stuff," said Dr. Washington Hill, head of maternal fetal medicine at Sarasota Memorial.
Even after going to a methadone clinic, Rose said she "still had the drug addict mind."
"I told them I couldn't sleep, that I was going to use again, and they would increase my dose," Rose said. "If you were pregnant they really didn't want you back on the street."
Rose delivered her son, Devin, by emergency Cesarean section on Feb. 8, 2008. Rose does not remember Devin's withdrawal from the drug addiction she created. She believes she was in denial or overcome with guilt and blocked it out.
Devin spent two weeks in intensive care and then went to Dr. Patricia Blanco. Blanco, a Bradenton pediatrician, was at first one of only two doctors in the area who would treat the infants.
"Everyone was saying, 'I don't know how to treat this,' and I was saying I don't know either but we have to," Blanco said. "We had to teach ourselves."
When the prescription drug abuse problem began affecting newborns in growing numbers, doctors struggled to react. The last guidelines from the American Academy of Pediatrics on treatment were issued in 1998, before the epidemic, and said a range of drugs, in varying doses, could be used to treat withdrawal.
Blanco and Rose delivered daily and weekly decreasing doses of methadone through a bottle tip until Devin's body no longer relied on it.
It took six months. Meanwhile, Rose was also being treated with methadone and trying to overcome her own drug addiction.
"There was a lot of shame and guilt," Rose said. "I knew it was my fault. He had to get methadone, a drug, for the first six months of his life because of me. No mother wants to know she is doing that to her child."
Hospitals are also struggling to find the best treatment. Different facilities treat withdrawal with different drugs, and there is still some debate over which ones are better and more cost-effective.
At Sarasota Memorial Hospital, staff are being trained in how to score the degree of the withdrawal symptoms, so doctors will be able to treat the withdrawal more precisely. What looks like a tremor of, say, level 5, to one nurse may look like a level 3 to another, and that could affect what dose of medicine doctors give the infant.
Diana Stark, a nurse in intensive care, describes the high number of withdrawing babies at the hospital in the past two years as "ridiculous."
From 2007 to 2009 the percentage of babies in intensive care at the hospital going through withdrawal has jumped from less than 2 percent to 10 percent. The early 2010 numbers are already coming in higher than last year.
Narcotics, like alcohol, are more toxic to a fetus than an adult. The liver and kidneys that in adults would act as filters are in a fetus not developed enough to do that, so the drug gets trapped. The enzymes present in adults that would help metabolize the drug are not yet developed enough to do that fully, either.
"You can't comfort them and they feel terrible, they don't sleep," Stark said. "Sometimes we try to carry them with us while we treat other babies."
Problem goes undetected
Part of what makes narcotics use by pregnant women dangerous to newborns is how often doctors miss it. Drug-testing -- like any medical test -- is not mandatory. Many of the pregnant women who abuse prescription drugs are employed and middle-class. They are good at keeping their secret.
"There's no question they sneak under the radar," Hill said. "It might not be clear to the doctor at all. The patient could be using five Oxycontins a day and you may not be able to tell, not like cocaine. If there's no history of drug abuse, then there's no way to know unless you sit down and ask or you have some suspicion."
Napolitano said he "doesn't trust anyone anymore" and suggests a campaign to encourage doctors to talk to every pregnant patient to try to ferret potential drug use and encourage testing.
"What else is there?" Napolitano said. "Should we drug test every baby born? Do you take the right of choice away?"
Rose was able to hide her drug abuse from her family and did not tell her doctor about it for fear her child would be taken away from her. But it was discovered in a drug test. Seven months into her pregnancy, she began going to a methadone clinic.
The babies of pregnant women abusing painkillers can also sneak under the radar because symptoms of withdrawal sometimes do not appear for up to two weeks after the baby is born -- long after leaving the hospital. Infants who are not treated for withdrawal by gradually being weaned off the drug can die. Untold numbers of infant deaths classified as seizures or SIDS (sudden infant death syndrome) could be linked to painkillers, Napolitano said.
Long-term impact unknown
Devin, now 2 years old, is "very typical and progressing normally," said Blanco.
But both she and Danielle are watching closely, and he is checked for developmental delays.
How babies exposed to painkillers will be affected by them later in life is not known. Doctors began trying to studying the effects of heroin -- which would have been similar to the effects of painkillers -- in the 1960s and 70s, but researchers quickly turned to the cocaine epidemic.
"We do need overarching policies and procedures on how to recognize these babies and assess them when they're born and assign treatment, and what kind of care and follow up they need," Dr. Ira Chasnoff, a leading researcher of maternal drug use who is based in Chicago. "All the research was headed that way and then the cocaine epidemic came along and people's attention turned to that. Now that we're seeing increasing rates of opiates again, it's receiving attention again."
Researchers are studying treatments for newborns and looking at methadone dosing for pregnant mothers. This summer the American Academy of Pediatrics is releasing updated guidelines for treating infants withdrawing from opiates.
What is known about the effects of cocaine, such as making children more impulsive or causing behavioral disorders such as attention deficit disorder, is partly because of brain scanning technology used in the 1990s. Nothing like that exists on the effects of heroin or painkillers.
"The long-term stuff is really speculative," said Dr. Mark Hudak, head neonatologist and researcher with Shands Jacksonville Medical Center, who is also heading the committee working on the upcoming national guidelines. "We don't really know, but there isn't any good information out there to suggest there is a really good chance that these babies from a long-term view are permanently impaired or affected. But it is an increasing issue."
Devin, with blonde hair in waves like his mother's, stays with his grandparents in Sarasota when Rose drives to the rehabilitation center twice a week for counseling and Bible study. She is not using drugs anymore -- her son was her inspiration to quit, she said -- and tries not to focus on how her addiction could continue to affect her son.
"I know it's possible that something could go wrong with him," Rose said. "Intellectually I know it's possible but my faith is bigger than that. God's got him."
By Anna Scott
Published: Sunday, July 18, 2010
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