The Globe and Mail
January 6, 2012
Babies born with dangerous dependencies to their mother's prescription painkillers are adding huge costs to the country's already overextended health-care budgets
Hours after his birth, stiff-limbed and trembling, Carter was whisked away to a bassinet in a neonatal intensive care unit and fed morphine through a dropper.
He broke out in sweats, a fine sheen clinging to his neck and scalp, when, weeks later, nurses started to wean him off. His mother, Laura, who asked to be identified by her first name only, knew exactly what he was going through: She'd experienced withdrawal before.
"That was the worst part. Knowing what it feels like, and knowing a little baby ... it's the worst feeling in the world, you know? You don't want your child to go through that."
Carter is one of a growing number of Canadian babies born with neonatal abstinence syndrome, an addiction to drugs their mothers took while pregnant. These aren't the "crack babies" that made headlines in the 1980s. Doctors attribute this rise to the use and abuse of prescription opioids: the painkillers fuelling Canada's fastest-growing addiction - and the methadone used to treat it.
Last year, at least 1,057 babies were born in Canada with NAS, an 18-per-cent increase over the year before, according to the Canadian Institute for Health Information. In Ontario, that number increased by a third in a year; in Manitoba, it more than doubled. As the incidents go up, so does the cost: The national average hospital stay for NAS infants last year was 15 days.
"There's a sense of urgency, for sure," said Gideon Koren, a pediatrician at the Hospital for Sick Children in Toronto. "The numbers have increased staggeringly."
Canadians pop more prescription opioids than almost any country in the world, behind only the United States and Belgium. The number of opioid-related deaths in Ontario equals the number of drivers killed in motor-vehicle accidents annually. Spurred by the spiralling human and financial cost of opioid addiction, some provinces are trying to better track these drugs and their use.
Last fall Ontario became one of the first jurisdictions in North America to design modernized guidelines setting out a standard of care for NAS. The recommendations include testing women of childbearing age for substance use and diagnosing babies with neonatal abstinence using the same updated scoring system.
In Vancouver a deceptively simple, previously unheard-of approach that keeps addicted babies with their moms while in hospital is proving successful. Facilities in Edmonton and Winnipeg are following suit.
Despite these steps, doctors worry that increasing incidence of NAS is outpacing the health-care system's ability to treat it.
"A number of clinicians mentioned the fact that they were seeing these babies - more, it seemed, every year ... for quite a long period of time," said Marilyn Booth, executive director of Ontario's Provincial Council on Maternal and Child Health, which wrote the new guidelines. "It's not just an Ontario problem. It's across the country."
Diagnosed, the condition is treatable. Babies are swaddled and given tiny doses of morphine to ease their withdrawal and monitored for weeks or months in a bassinet in a neonatal ICU before they're slowly weaned off.
But that diagnosis depends on a woman telling her obstetrician she's an addict, or a doctor recognizing symptoms once the baby is born. Those can be difficult to spot - as common as excessive crying or sneezing, or as severe as vomiting, rapid breathing and seizures. Some GPs may not realize painkillers prescribed before the woman conceived could affect her pregnancy.
If NAS goes undiagnosed, it can prove serious or fatal.
In her 17 years as a social worker at St. Joseph's Healthcare in Hamilton, Jodi Pereira has become accustomed to seeing babies hooked on their mother's meds. "It's right across the board," she said. "We used to assume it was always young moms - absolutely not any more." St. Joe's neonatal ICU gets about 40 newborn opioid addicts a year. The number and severity of cases are on the rise.
It was through St. Joe's that Ms. Pereira met Laura.
Laura swallowed and snorted street OxyContin for years after she was prescribed the painkiller for a back injury. On methadone, she had been clean for six months when she conceived. No one told her about the potential dangers of methadone if she got pregnant.
She did "a teeny bit of research online" when she and her husband decided to try for a third child. "In hindsight, I should have done more," she said.
When she told her GP she was pregnant, the doctor said the baby could spend months in hospital going through withdrawal. Laura was floored. Her first instinct was to get off methadone immediately, but going cold turkey can send the fetus into shock and cause a miscarriage.
Carter came through withdrawal and has been discharged from hospital. At home in his mother's arms, he dozes old man-style, ruddy, wrinkled hands half-clasped in front of him. "For the situation we were in, it was as good as it could be," Laura said.
Treatment gets trickier, and prognosis more grim, in areas with fewer health-care resources. More than 80 per cent of babies born at one remote reserve in Northern Ontario last year were hooked on medications taken by their mother. The closest neonatal ICU is hundreds of kilometres away.
Judy Desmoulins is health director of Longlac First Nation's community clinic. Over the past three decades, she's seen the 430-person Northern Ontario reserve go from one ravaging addiction to another. The latest, she said, is fuelled by painkillers.
Of the 17 babies born on the reserve last year, Ms. Desmoulin said, 14 were addicted to prescription drugs taken by the mother. They spend weeks or months getting treatment at the nearest neonatal ICU in Thunder Bay; in more severe cases, she said, they've needed surgery to patch strained intestines.
Ontario's new guidelines are meant to clear up uncertainty around diagnosing and treating newborns addicted to prescription opioids. Ms. Pereira, one of the authors, hopes they'll also put the condition higher on doctors' radars.
It's about time, Sick Kids' Dr. Koren said. "Obviously there's a huge, huge burden," he said. "Some of these babies need to stay in hospital up to 40 or 50 days. For $1,000 a day, you get a feeling what it means."
Ontario Health Minister Deb Matthews has made tackling prescription-drug abuse a personal priority. That includes care for infant addicts. "Can we do this better? Of course we can," she said. "These babies are at increased risk of harm.... We need to do everything we can to make sure they get the best start in life."
Increasingly, health practitioners in Canada argue that "best start" is keeping baby addicts with their mothers.
Fir Square, a clinic started eight years ago at the B.C. Women's Hospital in Vancouver, was the first in Canada dedicated to substance-using women and addicted infants. There, mothers and their babies are kept in the same room throughout the course of the infant's treatment. Multiple studies found babies who stayed with their moms during withdrawal needed less treatment and were discharged sooner. They were also more likely to stay in their mother's custody afterwards.
"Rather than demonizing the women and the babies, we're normalizing the care," said Ron Abrahams, the unit's founding doctor.
Sandra Seigel, deputy chief of pediatrics at St. Joe's, has a Fir Square facsimile high on her wish list, but knows the funding pitch for a condition like NAS is a challenge. "It's not everybody's favourite topic," she said. "It's hard, sometimes, not to feel angry at the mother. But it's really not her fault.... We'd better get good at treating this and taking care of these moms and babies, because we're going to be doing more and more of it."