reFramed S1E6: Reframing Your Thoughts on Substance Abuse During Pregnancy

According to the United States Department of Human and Health Services, over 10 million people misused prescription opioids in 2018. This was following the 2017 declaration of a public health emergency. While opioid-related deaths have slightly decreased in recent years, the rate of overdoses is still approximately four times higher than 20 years ago. The Centers for Disease Control and Prevention defines opioids as “substances that work in the nervous system of the body or in specific receptors in the brain to reduce the intensity of pain.” Substance abuse seems to have originated in the late 1990s as the medical community prescribed opioids without knowing how highly addictive they were. 

One of the consequences of this drastic increase in opioid abuse is the rise of women exposing their unborn children to these substances in utero, or in the womb. There is a good chance that at some point you have heard of a baby who has been born after being exposed to drugs in utero; these babies can experience withdrawal. Within the last ten years, the rate of babies withdrawing has significantly escalated from one every hour to one every 15 minutes, which is, unfortunately, the effects we will see as this epidemic intensifies. 

Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome (NAS) is when primarily opioids, but any legal or illegal substance crosses the placenta and exposes the developing baby to those substances. This can cause the baby to experience symptoms of withdrawal. 

Polysubstance abuse is when babies have multiple drug exposures and could have more withdrawal symptoms. It depends on the number of substances,  the frequency of substance use, and the purity of the substance. These are all things that are accessed at birth. 

In the NICU

Treatments in the Neonatal Intensive Care Unit (NICU) have progressed substantially over the last ten years, stated Kobi Tobin, a certified neonatal and pediatric nurse. Some symptoms of withdrawal include high-pitched crying, tremor, fast breathing, irritability, sneezing, and fevers that can affect both neurological and gastrointestinal systems. These symptoms of withdrawal are the components that then determine the need for nonpharmacological therapies, medication management, and adjusted medications. 

If the baby has low scores of symptoms the NICU will start with nonpharmacological or nonmedicated therapies. Soothing techniques are also a common practice such as skin-to-skin contact, rooming with a primary caregiver, vertical rocking, and the use of pacifiers. 

Rooming with the primary caregiver is one of the soothing methods that has shown to be the most beneficial of the nonpharmacological therapies. Even as caring and attentive as the NICU staff can be, it is not possible to have them in the room at all times. Rooming with the primary caregiver also promotes healthy bonding time and can meet the emotional needs of soothing and comfort.

Skin-to-skin contact—also known as kangaroo care—along with vertical rocking have been shown to have positive results of soothing, consoling, and decreased signs and duration of withdrawal. These are also forms of positive bonding time.

Swaddling has been shown to reduce signs of withdrawal and overstimulation of the senses as well. Loud sounds or other babies crying can stimulate the baby and cause a cycle of irritability and difficulty sleeping. 

Higher calorie diets are needed to replenish the calories burned during withdrawals. The irritability, tremors, and excessive crying require the baby to use more calories and energy than normal, so the extra calories help meet the baby’s nutritional needs.

NICUs also utilize volunteer cuddlers, when available, to help comfort the babies and make sure the needs of the baby are met. 

If symptoms persist after nonpharmacological therapies or if the baby scores high in the components for withdrawal,  the use of pharmacological or medicated therapies may result. The primary medications used are methadone and morphine, which are both narcotics. Both also have standard methods of weaning. The process starts with a therapeutic dose and titrates based on the baby’s symptoms. Both methadone and morphine have a standard method of weaning that includes monitoring their signs of withdrawal. Some studies have shown that using methadone, which is a shorter-acting narcotic, can wean the baby faster so that the baby can ultimately be discharged sooner. Sometimes as the process comes to an end, the last dosage can be the most difficult part as the baby learns to live without the substance. Even after the last dosage, monitoring for several days is still necessary to ensure there are no further signs of withdrawal.

My Experience with Substance Abuse

I remember the exact moment I was informed of the drug usage of my son’s biological mother. I was shocked because, during a prior conversation, I specifically asked her if the baby had been exposed to any substance abuse. I reassured her that it was a safe place for her to be honest. I just wanted to prepare myself mentally for the journey that could be waiting for us. To be completely honest, I felt betrayed when I found out. I felt like I had given her my trust and she had no regard for it. I now understand her position though and how hard it would have been to be completely transparent with me. Knowing now the fear she may have felt facing possible legal consequences, guilt, and judgment for those actions, I understand that it could not have been easy to confront that reality. Unfortunately, we only found out the truth through the court because she was incarcerated and given a drug test. Even though it was not the way I would have liked to find out, I am glad I had accurate information. 

When I got the phone call I was numb; I did not initially react. I just stared blankly at a wall in my parents’ pantry. My brother happened to be there too, and he just hugged me. I had no idea what lay ahead. I had no idea what to do, and I had no idea how to tell my husband. I did not know anything about the possible effects substance abuse could have on a baby. I only knew what I had seen on television. I was scared, but I knew this was something I was willing to pursue no matter the level of difficulty. I was already fully committed in my heart to this precious baby I had not even met yet. 

My son is a happy, healthy, sweet little boy and fortunately did not experience any symptoms of withdrawal. There is nothing I would change about him. I cannot imagine what my life would be like if I had allowed the uncertainty and the unknown to deter my decision. I blindly accepted this journey; I was unaware of all the resources and current research that would have provided some comfort and knowledge.

It is important to know that it is not a criminal offense to use illegal substances while pregnant. It is optimal that there be a safe and healthy environment for the baby to develop, but hopefully, knowledge of the law will provide relief for women as well as honest and accurate information for their health care providers. This may also encourage them to seek proper prenatal care to ensure that the baby is getting the nutrients needed; it may even encourage mothers to seek addiction assistance. 

Misconceptions About Substance Abuse

A very common misconception is that the baby is born addicted to drugs. Babies cannot be born addicted to drugs; they are instead born with a physical dependency. The difference is they cannot make conscious decisions to use drugs. Their little bodies are physically dependent on the substance or substances because the substances have been a consistent part of their development. This is why the substances have to be slowly removed from their bodies through therapy.

Understanding more about addiction cycles will help people to better understand the difference between a substance abuse disorder and a physical dependency on substances. Addiction is a chronic, primary disease connected to the reward centers of the brain which leads to the inability to control the use of substances. It can affect the brain and behavior. Again, these are actions and decisions babies are incapable of making.

Long-Term Effects of Substance Abuse

There are some long-term effects associated with specific substances. However, it is hard to fully know the long-term effects of NAS, especially considering how much their environment influences development.

Polysubstance abuse also makes it more difficult to determine if a specific substance is producing a long-term effect. It would be important to know what substances were introduced to the child in utero to monitor what possible side effects could exist. There are other factors, including genetics, that contribute to the response of the drug they were exposed to. 

Potential Adoptions

All the recent research, knowledge, and treatment of NAS should alleviate many of the fears and misunderstandings that might accompany previous opinions of babies born with NAS. Just like any child who was born biologically or who was adopted, you never know what challenges or obstacles they may face in the future. Even with the ideal in utero experience, children still have learning disabilities or fundamental delays. The environment makes a big impact on a child’s development and can make it incredibly difficult to differentiate the effects of nature versus nurture. It is hard to estimate what the developmental outcome would be if a child born with NAS  were raised by his or her biological mother, who may or may not have continued her drug usage.

Although my son did not experience the stages of withdrawal, I do understand that specific fear of the unknown. I can identify with the insecurities and thoughts of failure of those mothers who may not be able to provide adequate care. I can understand the severity of the what-ifs. I know what it is like to anticipate the very worst while hoping for the very best. These feelings and fears are so familiar to me that I can empathize with anyone struggling with these thoughts and fears. 

Interventions

Again, it is hard to know what the long-term effects could be but, like with any child, noticing early signs of delay is important. There is not any concrete scientific proof that all children born with NAS will have future disabilities, disorders, or delays. There are therapies to treat any delays and early intervention is key. Getting familiar with your resources from your pediatrician or other health care providers is strongly suggested. Also, knowing what signs to look for would be beneficial for early detection and intervention. It is important to have these conversations with your pediatrician, ask questions, and know what developmental stages and milestones your child should be reaching according to his or her corresponding age. 

Parenthood

The sad reality is that until there are breakthroughs in the opioid crisis, we will continue to see babies affected by NAS. We have to rely on the growing research and trust that the research will provide enough education and resources to all of the neonatal intensive care units. The care given in the NICU by all the wonderful, caring staff gives these babies the beginning they deserve. All the different techniques and therapies provide comfort and relief that can help ensure that these babies can leave the hospital and live happy, healthy lives. 

As potential adoptive parents approach the possibility of caring for a baby that has already endured so much, it is natural to have concerns for the future. Not knowing what challenges may arise in the upcoming years or feeling unequipped to meet the needs of the developing baby are hard fears to overcome. These concerns are certainly valid. The funny thing is that these are the same concerns and fears that parents face even when babies have a healthy in utero experience. This is the emotional roller coaster that every parent experiences initially when embarking on the journey of parenthood.

All parents of children who are biological or adopted have to be vigilant and flexible, and they have to learn to utilize their resources when an obstacle presents itself. Everyone enters parenthood with the highest expectations; many have also had to learn to quickly adapt. That is just what being a parent is all about. 

*More information on this topic can be found on season one, episode six of reFramed titled, “Reframing Your Thoughts on Substance Abuse During Pregnancy.”