NASHVILLE, Tenn. -- No one who hears it ever forgets the sound.
When newborn babies begin to withdraw from powerful drugs, they shriek at a high, telltale pitch. Cut off from the substances they ingested through their mothers, they convulse, projectile vomit or writhe from skin-scorching diarrhea.
Their tiny bodies shudder violently. They cannot be consoled.
The urge to help is overwhelming. But the debate over how to help has consumed Tennessee doctors, researchers and politicians alike — and has led them to wildly different conclusions in their efforts to speak up for these infants.
That's because drug-dependent babies are both heart-wrenching and expensive to care for. Meanwhile, state laws are divergent — and contradictory — in addressing the crisis.
Beginning this summer, two laws will be in effect at the same time. One encourages treatment and protects parental rights; the other threatens jail time for addicted mothers. Together, they leave doctors unsure what to tell their patients.
Babies born to addicted mothers are filling neonatal intensive care units in Tennessee faster than the health care system can figure out how to treat them. In the past decade, the number of babies in withdrawal has increased tenfold. Last year, 921 drug-dependent babies were born in the state.
The average cost to deliver a drug-dependent baby is $62,000, compared with $4,700 for a healthy child. Taxpayers bear the brunt of this cost — most of these babies and their mothers are on TennCare, the state's health insurance program for the poor.
The crisis has ballooned beyond Tennessee into a national issue. That's why Michael Botticelli, the White House's drug policy director, visited Monroe Carell Jr. Children's Hospital at Vanderbilt in April to learn about the faculty's urgent investigation into how best to treat drug-dependent babies.
Flanked by an entourage of white-coated staff, Botticelli toured dark rooms where thin-chested infants breathed rapidly in clear plastic cribs snaked with tubes. He met a new mother recovering from addiction. He planned to take what he learned about newborn drug withdrawal, known as neonatal abstinence syndrome (NAS), back to D.C.
"When you talk about forward-leaning states that are looking at NAS, you always hear Tennessee, Tennessee, Tennessee," Botticelli said.
Treatment vs. criminalization
The state has made its mark in trying to understand what triggers the painful symptoms in babies going through nicotine and opioid withdrawal. Researchers and insurers alike are looking for ways to reach out to and treat pregnant women with addictions.
That also has helped make Middle Tennessee a crucible for a roiling controversy about how to cope with the epidemic of babies in drug withdrawal, with elected officials offering solutions of their own.
But finding the right way to help is a dicey proposition. Women who know they are pregnant and addicted are often ashamed and fear that their babies could be taken away by the state. And the few doctors equipped to truly help them say they are baffled by the mixed signals being sent by lawmakers — to the point that they aren't sure what to tell patients.
Last year, legislators passed a law designed to encourage mothers with addiction to seek treatment. Called the Safe Harbor Act, the law says that if addicted mothers seek help, the Department of Children's Services cannot take their children into state custody based on the addiction alone.
But this year the legislature passed another law, one that tagged mothers with addiction as perpetrators of crimes against infants. As of July 1, police will be able to arrest a woman whose baby tests positive for drugs if she can't prove she's taking steps to get clean.
"It would just seem to me that any society that puts value on life would agree that these defenseless children deserve some protection and these babies need a voice," said Republican state Rep. Terri Lynn Weaver, who sponsored the law that criminalizes addicted mothers.
But civil rights activists and lawyers say they fear that the threat of criminalization will drive already-stigmatized pregnant addicts further underground, away from the care they need in the crucial period before babies are born.
Weaver insists her law can single out bad actors.
"These ladies are not those who would consider going to prenatal care. These are ladies who are strung out on heroin and cocaine and their only next decision is how to get their next fix," she said on the House floor. "These ladies are the worst of the worst. Again, I want to emphasize what they are thinking about, and that is just money for the next high."
Doctors who work with women battling addiction tell a different story.
Jessica Young treats pregnant women with substance abuse problems every day at her Vanderbilt clinic. She's the only Middle Tennessee obstetrician whose practice targets this patient population.
Young cringed as she recalled the legislative debate.
"When you don't have an understanding of addiction, treatment of addiction or the socioeconomic place these patients are coming from, then I don't think that you can make effective legislation," she said.
Young understands the desperate need to reduce the number of babies in withdrawal. But those babies are a result of complicated systemic problems, she says. Few are simply the children of criminals.
In fact, 42 percent of women who gave birth to drug-dependent babies in Tennessee last year were taking painkillers prescribed by doctors and no other drugs. While some of Young's patients first got hooked from recreational use, others took prescription painkillers after a cesarean section or injuries from a car crash and became addicted.
Some are children of addicts themselves. Young said many of her patients suffer post-traumatic stress disorder from physical and sexual abuse. Some have undiagnosed depression, which opiates ease.
Regardless of the jail threat, the medical community keeps searching for answers.
Research has shown that quitting the drugs cold can endanger a baby. Even tapering off an addictive drug can lead to relapse and be especially dangerous during pregnancy.
The gold standard in treatment is for a doctor to transfer the mother to a less harmful opioid, such as methadone or buprenorphine, and monitor its use.
These medications can still cause a baby to withdraw, but at least the odds improve. Mothers on this kind of therapy have a 60 percent chance of delivering a healthy baby, compared with a 30 percent to 40 percent chance for women who receive no treatment.
But women who need maintenance therapy drugs often struggle to get them.
To get buprenorphine, they must go to one of the state's few doctors with a special license. To get methadone, they must go regularly to a clinic — in Middle Tennessee there's one in Nashville and one in Columbia. Women must often pay out of pocket.
And many women of child-bearing age don't qualify for TennCare until they find themselves pregnant. That makes it difficult for an addict to access family planning or mental health preventive care before becoming pregnant.
The state's three managed care companies — Amerigroup, UnitedHealthcare's Medicaid subsidiary and BlueCross BlueShield's BlueCare program — are trying to reach these women earlier to ensure that more babies are born healthy. All have flagged drug-dependent babies as a major cost issue. BlueCross, for example, covered 775 such babies in 2013.
All three have launched efforts to help expectant mothers beat their addictions.
Addiction is a legitimate disease, says William Wood, Amerigroup's chief medical officer. He compares it to diabetes and notes that doctors routinely treat diabetic women for their illness and their pregnancy simultaneously.
But pregnant women with addiction face barriers of shame and fear.
With that in mind, Tennessee lawmakers passed the Safe Harbor Act last year.
The law "is something I could talk about with patients to help assuage their fears that they were doing the right thing by getting treatment, that if they continued to do what they were supposed to do, they wouldn't have to worry about losing custody," said Young, the Vanderbilt doctor.
While doctors and insurers struggle to bridge the disconnect between the impulse to help and the move by the legislature to punish, many women with addiction are left to fend for themselves.
Managed care companies, fueled by compassion and their bottom lines, try to reach these women and to reward them for asking for help. Doctors labor to learn more about addiction, to standardize care for mothers, to ease the suffering of babies.
All of this occurs against a backdrop filled with unknowns. Medical experts say they still don't know enough about drug-dependent newborns. They remain in the dark regarding the exact cause of withdrawal, the best therapeutic drug for addicted mothers and how dependency in an infant affects long-term childhood development.
What they do know is that some form of treatment is better than none, for mothers and babies. If the new criminal penalty prevents addicted mothers from seeking help during pregnancies, they say, it will amplify the problem lawmakers set out to solve.
And that, in turn, will further jeopardize the babies whose cries they claim to be hearing.
Shelley DuBois and Tony Gonzalez
7:23 a.m. EDT June 15, 2014
The Newhawks Crew
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