Keeping Families Together: Medication-Assisted Treatment Shows Promise for Mothers, Children of Opioid Crisis
"They were coming to the hospital, no prenatal care, no medication-assisted treatment, so the babies were worse. (But now) the moms are getting treated. We're trying to relationship build, get them on their right two feet," said nursing manager Lisa Shafer.
The Lima News
By Mackenzi Klemann
LIMA, Ohio -- Eighteen weeks pregnant with her third child, Amber Hardeman is optimistic she will soon regain custody of her two daughters and take her baby-to-be home when she gives birth later this year.
She wasn't always this optimistic.
Hardeman, 31, lost custody of her children in May after relapsing on heroin, ending six years of sobriety for the expectant mother, who was first introduced to heroin by friends in her early 20s.
Homeless and without her children, Hardeman soon turned to Suboxone -- a popular method of treating heroin and opioid misuse -- to alleviate her cravings. But Hardeman's father, a strong source of support in her sobriety, died in July. Then Hardeman learned she was pregnant with her third child, whose gender she hopes to learn in several weeks.
I did beat myself up about it then," she said. "But you just pick yourself back up and keep moving forward. You can't stay in a slump, especially with how things are now. You could end up dead. A lot of people are dying nowadays."
Hardeman switched from Suboxone to Subutex, another opiate blocker being prescribed to pregnant women with opiate misuse disorders, and is now one of 13 women enrolled in Embrace.
The program, a partnership between Mercy Health-St. Rita's and Coleman Professional Services, was developed to help opioid-dependent pregnant women and postpartum mothers stop using heroin and, ultimately, retain custody of their children.
Embrace combines medication-assisted treatment -- Subutex -- with counseling and support services to help women find work and stable housing, lessening the probability of relapse.
Hardeman is feeling better. The Subutex has had fewer side-effects than Suboxone, which occassionally gave Hardeman stomach aches. And she's much more optimistic about her future now that she's several months into treatment, no longer homeless and no longer seeking out heroin to numb her pain.
"I have kids to live for," she said. "Not only my kids, but myself."
Seeing the Need
Several years ago, Dr. Marilyn Kindig started seeing more pregnant women with substance use disorder, whose newborns were sent to special care units with neonatal abstinence syndrome, otherwise known as withdrawal.
The condition is painful. Children suffering withdrawal are often restless with a high-pitched cry. They may suffer tremors, fever, sweating, stuffy nose and vomiting and may even have trouble sleeping or feeding. More severe cases may lead to seizures, among a host of other symptoms.
The severity of neonatal abstinence syndrome depends on several factors, including the age of the mother, her genetics and the type of substance she used during pregnancy, said Rick Massatti, chief of substance use disorder treatment services with the Ohio Department of Mental Health and Addiction Services.
Treatment often involves rocking, cuddling, swaddling and swinging to calm the infants while they suffer withdrawal, while children with more severe symptoms may be given medicine to alleviate symptoms.
There were nearly 2,000 NAS hospitalizations in Ohio in 2018 alone, according to data compiled by the Ohio Hospital Association and Ohio Department of Health, but hospitalizations are down from their 2016 peak of 2,223.
The problem caught the attention of former Gov. John Kasich's administration, which launched a pilot program in Athens, Columbus, Cincinnati and Cleveland to expand treatment options for opioid-dependent pregnant women.
The program has since expanded to Lima with Embrace.
But Kindig was one of the first obstetricians and gynecologists in Lima to offer medication-assisted treatment to pregnant women.
"(It's) very difficult to get somebody to do this type of work," Kindig said. "The clients are difficult. Most often they don't tell you what they're thinking. Most often what they tell you isn't correct or true. And to try to see through that and work with them to keep their housing, keep their children and keep their families intact is very difficult."
Kindig left her OB-GYN practice to see substance abuse patients at Coleman, eventually broadening her client base to include pregnant women. She now splits her time between Lima and Dayton, where she teaches residents and cares for patients at Wright State University.
"As pregnant women came in, they all came to me," Kindig said.
While there are several medications popular for treating heroin use -- such as suboxone, vivitrol and methadone -- Kindig uses Subutex for her pregnant clients.
That's the safest for mom and baby," said Heather Ruble, a care navigator with Coleman Professional Services in the Embrace program, which formally opened to patients last October. "It doesn't have that separate blocker like the naloxone, so that isn't interfering with anything that's been tested that's ever going to harm the baby."
The average stay in the NICU for a child with NAS ranges from 12-15 days, with most spending an average of 13 days in the NICU in 2018, according to Ohio Hospital Association data.
Kindig said her clients' children are spending much less time in the neonatal intensive care unit, often leaving the hospital within one week of delivery. Ruble said she's seen similar results with women who participated in Embrace, which works with women through pregnancy and up to 18 months postpartum.
"Their babies go to special care for a short observation, much shorter than if they would have been on an opiate or heroin," Kindig said. "And they take their babies home. We have very few clients that don't."
Hardeman was so worried that using Subutex during pregnancy would trigger a children services investigation -- and that she would ultimately lose custody of another child -- that she considered stopping treatment altogether.
But quitting treatment while pregnant could increase the probability of relapse, which would make Hardeman more likely to lose custody and increase her child's chances of suffering a more extreme withdrawal at birth.
Sarah Newland, an assistant prosecuting attorney who oversees cases for Allen County Children Services, said the agency is required by law to provide reasonable efforts for the mother and child to stay together, unless doing so jeopardizes the child's safety.
Mothers may be tested for illegal substances after the child is born, Newland said, and the agency will need to see that the mother is continuing to stay engaged with treatment post-delivery.
Children services may also offer supervision to ensure the child remains in the home, but when that is not possible, Newland said the agency looks for placements with family or kin before turning to foster care.
That baby's the motivating factor for her," said Lisa Shafer, nursing manager for Mercy Health-St. Rita's labor and delivery department, who is also involved in the Embrace program.
The labor and delivery department at St. Rita's has seen fewer infants admitted to the nursery with neonatal abstinence syndrome since 2015. NAS admissions fell from 34 in 2015 to 13 in 2019, which Shafer believes is related to mothers seeking treatment earlier in pregnancy.
"They were coming to the hospital, no prenatal care, no medication-assisted treatment," Shafer said, "so the babies were worse. Everything was disorganized and chaotic. They weren't ready to deal with their addiction. (But now) the moms are getting treated. We're trying to relationship build, get them on their right two feet."
Seeing the Effects
Loretta Mault, 31, took her daughter home after just five days in the NICU.
"She had small tremors," said Mault, who took Subutex during pregnancy after signing up for the Embrace program. But there were no major complications, such as the high-pitched cries, restlessness and vomiting typical for infants suffering withdrawal.
Mault turned to heroin several years after developing a dependence on prescription pain medication, which had been given to her after the birth of her fourth child, a son, now 3.
She eventually overdosed, but a sergeant who responded to the call referred her to the clinic at Coleman rather than press charges.
"He gave me a chance to get help," she said.
Mault has since regained custody of her four older children and is caring for her youngest, a daughter, who was born just two weeks ago.
"Her tremors weren't constant like you see in the videos of parents who are on opiates. It was just for a second, and she quit," Mault said.
"Now that we're home, she doesn't have withdrawal symptoms. The only time she cries is when she's hungry or has a dirty diaper."
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Access a guidance publication from the U.S. Department of Health and Human Services and the Administration for Children and Families intended to support the efforts of states, tribes, and local
communities in addressing the needs of pregnant women with opioid use disorders and their infants and families: