Dr. Craig Towers says he's asked all the time by his pregnant patients who are addicted to opioids whether he can help them get completely off drugs so their baby doesn't suffer agonizing drug withdrawal symptoms after birth.
Towers is a perinatologist in Eastern Tennessee, the Appalachian epicenter of America's opioid addiction epidemic. He and his group, High Risk Obstetrical Consultants in Knoxville, see 300 to 400 opiate-addicted pregnant women a year.
Like nearly all doctors across the country, Towers previously would tell patients no, because detoxification would risk premature labor or even fetal death. Instead, he recommended that they receive medication-assisted drug maintenance therapy with methodone or buprenorphine through pregnancy.
That's the long-standing recommendation of the American College of Obstetricians and Gynecologists, even though that means their baby is likely to suffer neonatal abstinence syndrome (NAS) and have to be slowly weaned from the opioid drug. That takes place in a hospital over three to 10 weeks of costly treatment.
“They said they wanted to be off drugs, and we said it's bad,” said Towers, a professor of obstetrics and gynecology at the University of Tennessee Medical Center.
Challenged by his patients' insistent requests, however, Towers dug into the research literature and found several obscure studies suggesting that detox during pregnancy is not harmful. So he and his colleagues launched a five-year observational study of 301 opiate-addicted pregnant women who underwent four methods of detoxification. The results were published this month in the American Journal of Obstetrics and Gynecology.
They found no adverse fetal outcomes related to detox. In addition, for women who went through detox treatment with accompanying intensive behavioral therapy, only about 17% rate of their newborns suffered NAS.
The findings may prompt more physicians to decide that it's safe to break with standard clinical practice and to offer detoxification treatment to their pregnant patients to get them completely off drugs before delivery, which could sharply reduce the number of babies born with drug withdrawal symptoms.
“I'm not saying, 'Change what you're doing and start detoxing everyone immediately,' ” Towers said in an interview. “But for 40 years we've not been doing that because we thought it was harmful. We've now shown that's not true. This is doable but we have to set up behavioral programs because otherwise the relapse rate is too high.”
The study's findings were exciting news for Dr. Mark Hudak, a pediatrics professor at the University of Florida College of Medicine–Jacksonville, who co-authored a 2012 article in the journal Pediatrics on clinical protocols for treating opiate-addicted pregnant women and infants with neonatal drug withdrawal.
“I'm happy to see someone has had the courage to provide outcome data,” he said. “People will scrutinize this and say there is some evidence this isn't dangerous. This opens the door to further refinement to do this in a safe way to achieve the best results.”
Hudak said doctors have shunned detox treatment for pregnant women because it went against clinical recommendations, and those who wanted to try it often were blocked by hospitals fearful of the liability risk. Expanding detox treatment, he added, could have a positive long-term impact. That's because once a pregnant woman is placed on maintenance drug therapy, she will be on it for future pregnancies as well, putting all her babies at risk for NAS.
Towers' study is timely because the number of babies born with NAS has increased five-fold from 2000 to 2012, with more than 21,000 infants suffering from the syndrome in 2012, according to the National Institute of Drug Abuse.
Babies born with NAS may suffer seizures, high fevers, vomiting, diarrhea and severe distress, requiring weeks of inpatient treatment with diminishing drips of morphine or methadone. There are many unanswered questions about the best withdrawal treatment for NAS babies and the long-term effects of the drug treatment. Hospital treatment for these babies typically costs $50,000 to $60,000.
In Tennessee alone, treatment for NAS babies cost the state Medicaid program more than $60 million last year, Towers said. He noted that if detox treatment succeeds in significantly reducing the number of NAS cases, the state could take those millions in savings and generously fund addiction treatment programs for pregnant women. He's currently talking with state Medicaid officials about developing more inpatient and outpatient programs.
Towers is working with Dr. Geogy Thomas in the small eastern Tennessee town of Jellico—where about 60 babies with NAS were born last year—to launch a comprehensive inpatient program at Jellico Hospital to provide detox treatment for opiate-addicted pregnant women. The Dayspring Family Health Center, where Thomas is medical director, just received a two-year federal grant for outpatient detox services for these patients. He's trying to persuade Medicaid managed-care plans to cover these services and provide adequate payment rates to make it viable.
“Our idea is to get the girls off drugs before delivery, then equip them to be better moms,” Thomas said. “We could save the state lots of money, and save the babies the anguish of withdrawal for six weeks.”
In Towers' study, one group of patients received slow outpatient treatment with buprenorphine, combined with intensive behavioral healthcare; the NAS rate for their babies was 17.2%. Two groups received more rapid inpatient treatment with buprenorphine. Of those two groups, the one that got intensive residential behavioral care had an NAS rate for their babies of 17.4%, while the group that did not receive the same level of behavioral care had an NAS rate of 70.1%. A fourth group of women were incarcerated, mostly for drug-related offenses, and went through cold-turkey withdrawal. Their babies' NAS rate was 18.5%.
Over the next several years, Towers foresees that further research will show which women are best suited for rapid inpatient detox treatment or more gradual outpatient therapy, and which ones are less likely to succeed in detox and should receive standard maintenance therapy through pregnancy.
He said more than 90% of his opiate-addicted pregnant patients want to be off drugs, and are surprised when told about the option of detox treatment because they thought it would kill their baby. “We don't shame them into doing this,” he said. “They are motivated because they have someone else they are responsible for.”