Lisa Pulley's fourth daughter was born last week. She put the first three up for adoption long ago because she couldn't -- really, wouldn't -- stop using crack cocaine and heroin long enough to focus on them.
The eighth-grade dropout has never held a job. She has been too busy selling sex for drugs, living on the street so she could afford drugs. There was no room in her life for children.
But this time, Pulley swears, she is ready. This time, she keeps telling herself, will be different. This time, she wants to keep the baby.
When the 37-year-old became pregnant, she enrolled in an intensive drug treatment program in Baltimore -- one where she has been getting methadone to help fight against her drug cravings.
In 40 years as a treatment for heroin addiction, methadone -- a synthetic opiate that satisfies the addict's physical hunger for the illicit drug -- remains the gold standard. But its effects on children born to women who take it still are not fully understood. The U.S. Food and Drug Administration has not approved its use in pregnant women, and about half of the babies will suffer a potentially harmful withdrawal after birth.
Still, addiction researchers say such babies are much better off than those whose mothers continued to shoot heroin. The greatest danger to the fetus of a heroin addict comes from the withdrawal the mother constantly cycles through as she searches for her next hit. And those who are prostituting themselves to procure the drug are exposed to the risk of contracting new infections, being raped or even killed in the process.
Yet the women still are taking a narcotic, at a time when many expectant mothers worry about having a sip of wine or drinking a cup of coffee.
"Most people, when you say 'methadone and pregnancy,' it's like, 'Oh my God, what are you doing?'" said Vickie L. Walters, program director at the Center for Addiction and Pregnancy at Johns Hopkins Bayview Medical Center.
"The ideal would be that she use nothing, that nothing gets into her system. But that's not the norm and that's the exception. It's better to have them on a safe, legal medication."
Dr. Christopher Welsh, an addictions psychiatrist at the University of Maryland Medical Center who treats pregnant women regularly, said "pregnancy just goes better" when addicts are on methadone. On methadone, they are not high, as the long-acting drug allows them a feeling of stability. Still, "methadone hasn't been studied as well as we would like," he said.
There is no direct evidence that babies are harmed over the long term by methadone. Often the children grow up in chaotic homes, where they may see violence, be exposed to lead paint and subpar schools or have mothers who return to hard drugs and the lifestyle that goes with them.
"It's hard to tease out how much is the drug specifically and how much is the environment," Welsh said. According to 2007 federal data, approximately 5 percent of pregnant women aged 15 to 44 years admitted to having used illegal drugs in the past month, significantly lower than the 9.7 percent of non-pregnant women in that age group. Many also use alcohol or use cigarettes while pregnant. They know the risks that drug use poses to their unborn children. But that doesn't mean they are ready to abandon habits that have become part the fabric of their lives.
"There's a tremendous amount of guilt and stigma that these women walk in the door with," said Hendrée Jones, research director at the Center for Addiction and Pregnancy. "They know putting a drug inside their body is harming them and the baby. They shoot up and they cry."
The Bayview center, which is also known as CAP, has been around for nearly 20 years. It was born out of a methadone clinic that in the mid-80s started seeing a handful of pregnant women at its doorstep. Women weren't its usual clients then, let alone those expecting children.
The director of the clinic wasn't comfortable giving methadone to pregnant women, Walters said. But he did want them to get prenatal care. The women weren't interested. So he brought in an obstetrician and made check-ups mandatory if they wanted methadone. He got 100 percent compliance.
In 1991, CAP opened its doors. The idea was a "one-stop shopping model," Jones said. There is methadone distribution, individual and group therapy, nutrition counseling, an obstetric clinic and a pediatric clinic. Most of the women are in extensive outpatient treatment, but many start out in the residential unit, which can be used for detox or as a timeout of up to 28 days from a drug-using life on the streets.
CAP used to offer more programs than it does now, but 98 percent of its patients are on medical assistance, and Medicaid doesn't pay for what it once did. Once the center sent vans into the neighborhoods to pick up the women; now staff give out bus fare. They used to treat women for two years following the birth of their babies. Now, they're covered only for a maximum of three months.
Time was, women could come in for counseling seven days a week. Now only the newer patients are allowed on the weekends.
On a recent morning in group therapy, crowded into a small room clearly too warm for them, the women complain about that.
Several say they would come on Saturdays or Sundays if they could. Many have lost custody of their children or are living away from home while they try to shed the drug life. They find themselves with little to do. "Having idle time on the weekends is dangerous," one says.
They are talking about success stories today, as they absently fidget in their uncomfortable seats. One chomps on Fritos from the vending machine. Another puts stickers on her painted toenails. Another is cleaning a spot off her T-shirt with a Tide pen. But they are all listening to the stories -- some familiar, some inspiring.
One woman, in a flowered tank top, proudly announces she is getting an unsupervised visit with her children in a few days, the first time they have all been together in two years. One is now healthy enough to start planning a birthday party for her two young sons -- a celebration she missed because of her addiction. The others applaud.
Another woman, though, is worried. Next week marks the anniversary of the death of another baby she had and she isn't sure she is strong enough to stay clean.
"You have come so far," one of the women tells her. The others nod. This is the only place where they get this kind of affirmation that yes, they are on the right track.
But a spirited debate soon erupts about whether they are technically clean. Many of the women are on methadone -- about half of the women are put on the drug at enrollment, Walters says, but the rate rises to 85 percent by the time of delivery. One says she went to a narcotics anonymous meeting where she took a key chain for being sober, only to be scolded by another participant who told her being on methadone is just like being on heroin as far as she was concerned. She was still using a narcotic as a crutch to get her through the day.
The women in CAP are a racially diverse group, with more white patients than black in recent years. The women typically are older and have been through drug treatment before. Still, a quarter will test positive for drugs beyond methadone when they give birth. Some of the women even return to the program when they are pregnant again.
Walters doesn't know the relapse rate. She doesn't have the funds to follow the women.
With so little known about methadone and its effects on moms and babies, research is a major component of CAP. A current study, being done at eight sites across the world, is comparing the outcomes of babies whose mothers have been on methadone versus those who have taken buprenorphine, a similar drug which comes in pill form, freeing users from daily trips to the methadone clinic.
A pilot study found the outcomes the same for mothers but babies spent an average of 13 fewer days in the hospital when they took bupe, Jones says. The positive trend, though not definitive, was for babies with birth weights and head sizes closer to the norm. Jones said she hopes her study will provide the data necessary to help get each drug FDA-approved for use by pregnant women.
Another study is looking at whether different doses of methadone have an impact on whether a baby suffers withdrawal -- called neonatal abstinence syndrome -- or how severe it is.
Juliann Mason, 28, was forced off drugs when she was in the city jail for three months last year. It was long enough for her to stop using the heroin she came to by way of Vicodin and OxyContin abuse.
But as soon as she was out the door she was using again. And then she got pregnant. Her daughter is due in August. Now she is on methadone and working hard at recovery. She doesn't want to live on the street anymore or dance on the Block. She wants to go to nursing school. She wants to be able to care for her 10-year-old daughter, who is in the custody of her parents.
But for her, that nine months isn't long enough to get well. So she will put her child up for adoption. "I've made a lot of bad decisions in my life," she said. "I feel like this is the best decision I've made in my life." When the baby is born, Mason plans to detox from methadone, too, a blind detox where the amount is slowly lowered and she won't know how much she is getting.
She wishes there was a way to not be taking methadone while she is pregnant, but she feels as though this is what is best for her now.
"Addiction is really a disease," she said. "It's like diabetes. When somebody gets pregnant they don't stop having diabetes."
Pulley, the woman who had her baby last week, says the program has given her new hope.
"I don't have to be miserable," the Baltimore woman said. "I don't have to live in abandoned homes. I don't have to have sex with strange men."
The way she sees it, this latest pregnancy "wasn't a bad thing."
"It was a beautiful thing -- or I'd probably still be out there."
By Stephanie Desmon
June 22, 2009
The Baltimore Sun