Ad­dic­tion, preg­nancy and and a chance to en­gage

As the num­ber of ba­bies born with opi­oid ad­dic­tions climbs, so do the ser­vices help­ing preg­nant women — in­clud­ing ev­ery­thing from mo­bile mid­wives to methadone pro­grams

The Hamilton Spectator - - FRONT PAGE - MOLLY HAYES

A park bench. A Tim Hor­tons.

IF A WOMAN IS PREG­NANT, at risk and in need of care, they will meet her wher­ever she is.

Across Hamil­ton, a team of mid­wives are ready to serve some of the most vul­ner­a­ble moms-tobe. The Ma­ter­nity Care Team is ready 24/7, await­ing calls from the Shel­ter Health Net­work or other so­cial ser­vice agen­cies to meet home­less preg­nant or post­par­tum women with­out a health­care provider.

“We will be there within the hour, or when­ever she wants,” says Lisa Nussey, one of eight mid­wives on the team.

And they will meet her any­where — at a shel­ter or methadone clinic, wher­ever she is com­fort­able. They carry their equip­ment with them so that they are es­sen­tially a mo­bile pre­na­tal unit.

The team, which op­er­ates on a vol­un­teer ba­sis, has re­ceived roughly four to six calls per month since its in­cep­tion in 2013.

Not ev­ery woman they meet has drug or ad­dic­tion is­sues — they also work with refugees or young women flee­ing do­mes­tic vi­o­lence, for ex­am­ple — but Nussey says drug use is “preva­lent.”

But if a mom is strug­gling with sub­stance use or abuse, they will re­fer her to the Ma­ter­nity Cen­tre at the David Bra­ley Health Sciences Cen­tre down­town, which is home to a spe­cific pro­gram for preg­nant women with ad­dic­tions.

Their goal is not to be the mom’s pri­mary care provider; they just want to en­sure she gets ba­sic care ahead of her de­liv­ery.

IT’S A HARM-REDUCTION ap­proach, Nussey ex­plains. Their goal is to reach women be­fore they show up at the hos­pi­tal “34 weeks preg­nant and … bleed­ing.”

Nussey says it should come as no sur­prise that pre­na­tal care might be low on a long list of pri­or­i­ties for a woman who doesn’t have ac­cess to shel­ter.

“As a sec­tor, peo­ple just don’t ap­pre­ci­ate how dif­fi­cult it is to make it through the day,” she says.

Es­pe­cially with­out a health card, for ex­am­ple, it can be dif­fi­cult to ac­cess even ba­sic health-care ser­vices like blood work.

The mid­wifery model, they be­lieve, is a good fit for these cases.

“One of the things peo­ple re­ally like about mid­wifery is that we can do home vis­its,” Nussey says, not­ing she came to the field from a so­cial jus­tice per­spec­tive.

She gives an ex­am­ple of a 15-year-old liv­ing in a shel­ter with her mother. She was 38 weeks preg­nant when Nussey’s team con­nected with her. But in just two days, they were able to get all of her pre­na­tal care done.

Their pa­tients’ files are for­warded by the team to the lo­cal hos­pi­tals, so when­ever and wher­ever a mom shows up to de­liver, the in­for­ma­tion is there. Even hav­ing ba­sic in­for­ma­tion like where the pla­centa is can make a big dif­fer­ence dur­ing the chaotic de­liv­ery process, she ex­plains.

Four years in, they are try­ing to raise aware­ness about the pro­gram. Be­cause there is a high turnover rate at so­cial ser­vice agen­cies, she says it can be hard to keep peo­ple in­formed. They also have a longer-term goal of se­cur­ing fund­ing.

“We need to keep data, and we are try­ing to do that re­search on how many women aren’t ac­cess­ing pre­na­tal care and who they are,” she says.

And they are con­stantly try­ing to ed­u­cate about the re­al­i­ties of ad­dic­tion.

“It’s a choice to view the (opi­oid) epi­demic as a law-and-or­der is­sue. That’s a de­ci­sion. You can also view it as a pub­lic-health is­sue — and if you do, you view it very dif­fer­ently,” she said. “Es­pe­cially given what we know about how hard it is to be des­ti­tute and poor.”

BUT IN THE MIDST of an opi­oid cri­sis — one that is claim­ing thou­sands of lives across Canada ev­ery year, and ru­in­ing so many more — not all who use or abuse drugs are des­ti­tute and poor.

When new­born baby Carter spent a month in hos­pi­tal, his mom Ad­ina told only close friends and fam­ily why he was there.

“I def­i­nitely didn’t want peo­ple to know that he was in with­drawal be­cause I had a drug prob­lem,” she says.

Be­cause Ad­ina, 27 — who asks that only her first name be used be­cause of the stigma around ad­dic­tions — was in a methadone treat­ment pro­gram when she got preg­nant, her baby was born with neona­tal ab­sti­nence syn­drome (NAS), mean­ing he was born in opi­oid with­drawal.

When she dis­cov­ered she was preg­nant, she was afraid of go­ing through with it. What would the methadone do to the baby? What would peo­ple think?

Af­ter all, she and her boyfriend were only re­cently clean af­ter years of opi­oid abuse, stem­ming from doc­tor-pre­scribed painkillers, which had spi­ralled into street drug use be­fore fam­ily and friends’ in­ter­ven­tion.

At 21, while liv­ing and work­ing in Toronto, Ad­ina was di­ag­nosed with in­ter­sti­tial cys­ti­tis (ul­cers on the blad­der) — a painful con­di­tion with no real cure. To man­age the pain, she was pre­scribed Per­co­cet and Di­lau­did.

She has an ad­dic­tive per­son­al­ity, she ac­knowl­edges now — in fact, it was partly recre­ational ke­tamine use, pop­u­lar in the Toronto club scene, that led to her blad­der is­sues. But the opi­oids were some­thing new. With­out them, she could barely leave the house with­out hav­ing to im­me­di­ately run back in­side to use the bath­room.

“I needed them,” she says. “I couldn’t have done any­thing with­out the opi­ates.”

Soon her pre­scrip­tion was not enough.

IT WAS AROUND THIS TIME she met her boyfriend, Chris. He had been home­less be­fore Ad­ina met him, hav­ing long strug­gled with ad­dic­tions him­self that stemmed sim­i­larly from doc­tor-pre­scribed pain med­i­ca­tion af­ter a car ac­ci­dent at 19 years old.

“That’s when it kind of got to an­other level … when there are two peo­ple, you’re kind of feed­ing off each other,” she says.

Her in­jec­tion use lasted just a few months be­fore friends — wor­ried about this seem­ingly bizarre turn in her pre­vi­ously “nor­mal” life — called Ad­ina’s mom. This wasn’t like her.

“They were sick,” her mom says. She begged her daugh­ter to come home to Burling­ton. And with her lease about to ex­pire, Ad­ina even­tu­ally agreed — on the con­di­tion that Chris came, too.

In the spring of 2015, they moved into her dad’s place in Burling­ton. Her mom got the two fam­ily doc­tors and into the Well­be­ings pain clinic where, for the first time, they started on a methadone pro­gram. Things were look­ing up.

One month later, Ad­ina got preg­nant.

TO­DAY, CARTER is 17 months old and a healthy, happy baby. On a Wed­nes­day morn­ing in March, he is hap­pily run­ning around, bang­ing toy trucks on the hard­wood floor of his grand­mother’s sub­ur­ban Burling­ton home. He says ba­sic words like mama and dada but oth­er­wise com­mu­ni­cates through gur­gles and shrieks.

Ad­ina watches him with a smile. Sip­ping tea at her mom’s din­ing room ta­ble, she ac­knowl­edges she does not fit most peo­ple’s stereo­typ­i­cal im­age of a mom strug­gling with ad­dic­tions.

“Be­fore I was preg­nant, I’d be at the (methadone) clinic and see preg­nant women and be like, ‘Is that even pos­si­ble? What are you do­ing right now?’” she ad­mits. “You think it’s trashy. But now I won­der if peo­ple think that of me when I’m at the clinic with him … but what are you sup­posed to do?”

Ad­ina’s story is part of a grow­ing nar­ra­tive across Hamil­ton, On­tario and Canada. As opi­oid pre­scrip­tions rise, and over­dose rates rise, so do the rates of ba­bies be­ing born in opi­oid with­drawal each year.

For ev­ery 1,000 ba­bies born across the prov­ince be­tween April 2015 and March 2016, 5.9 were di­ag­nosed with NAS. The na­tional rate was 4.2 births per 1,000 — a stark in­crease from a decade ear­lier, when the pro­vin­cial and na­tional NAS birth rates were both 1.8 per 1,000.

In Hamil­ton, there were roughly 45 NAS births in 2015 — a num­ber that rose to roughly 62 last year.

It’s an alarm­ing in­crease. But health-care providers point out there is an­other trend: a grow­ing num­ber of moms, like Ad­ina, who are get­ting onto sta­ble methadone pro­grams be­fore or dur­ing their preg­nan­cies. And that, doc­tors say, is a very good thing. Ac­cord­ing to a 2015 study on neona­tal with­drawal by the In­sti­tute for Clin­i­cal Eval­u­a­tive Stud­ies (ICES), doc­tors noted that as de­liv­ery ap­proached, more and more women were switch­ing to methadone from other opi­oids — from 29 per cent of the women hav­ing been pre­scribed methadone one to two years be­fore de­liv­ery, to 53 per cent in the 100 days be­fore de­liv­ery.

The num­ber of women pre­scribed non-methadone opi­oids also dropped from 23 per cent one to two years be­fore de­liv­ery to 11 per cent in the 100 days be­fore de­liv­ery.

This is im­por­tant be­cause women who mis­use opi­oids are more likely to have pre­ma­ture and un­der­weight ba­bies. But women who switch to methadone, the study says, are more likely to have their ba­bies at term and with full birth weights.

“NAS is a treat­able con­di­tion. It doesn’t have any long last­ing se­que­lae for the baby,” says Dr. Suzanne Turner, a fam­ily physi­cian at St. Michael’s Hos­pi­tal and the study’s lead au­thor.

“I mean, as some­one who treats women with ad­dic­tions and par­tic­u­larly in preg­nancy, I am happy that these women are get­ting ev­i­dence­based treat­ment,” Turner says.

“In many ways, if some­one (with ad­dic­tions) wants to par­ent on methadone … it is the best thing they can do. They are treat­ments that we know work to avoid the con­stant cy­cle of ad­dic­tion.”

What would the methadone do to the baby? What would peo­ple think?

AD­INA AC­KNOWL­EDGES she was lucky. She had her mom, who shut­tled her to ev­ery ap­point­ment.

And she cred­its the Well­be­ings clinic with con­nect­ing her with the re­sources she needed.

“They were so amaz­ing. Very pro­fes­sional and not the least bit judg­men­tal,” she says. “A lot of methadone clin­ics are a bit rough around the edges and not the hap­pi­est of places … but Well­be­ings is very clean, and a very pos­i­tive en­vi­ron­ment to have to go to ev­ery week.”

It was Well­be­ings staff who con­nected her with the Ma­ter­nity Cen­tre and the NAS pro­gram at St. Joe’s. She re­mem­bers how ner­vous she was dur­ing her first ori­en­ta­tion meet­ing at the hos­pi­tal, where she met so­cial worker Sarah Simp­son.

“And Sarah Simp­son was so good to you,” her mom says to her. “She re­ally un­der­stood that you felt (em­bar­rassed), and she said, ‘It’s not what it’s about. This is about pro­tect­ing ba­bies, and we have to watch (out for them).’ And you were fine.”

They made her feel proud of be­ing on methadone and get­ting the treat­ment she needed — rather than sham­ing her for tak­ing some­thing bad for her baby.

“They would re­as­sure her, ‘It’s OK, you’re do­ing the right thing. You’re get­ting treat­ment and it’s go­ing to be all right,’” her mom re­calls.

DUR­ING THE MONTH that Carter spent in the neona­tal in­ten­sive care unit (NICU) at St. Joe’s for mor­phine treat­ment, Ad­ina and Chris were able to stay in a bunk room (or “care by par­ent” room, as they call them) on the ma­ter­nity floor, to be nearby and feed and care for Carter.

If mom used non-opi­oid drugs dur­ing her preg­nancy, like co­caine, ba­bies will be un­der ob­ser­va­tion for an ex­tra two or three days af­ter birth. But be­cause the with­drawal from opi­oids — whether it’s pre­scribed drugs, methadone or il­licit opi­oids — is more in­tense, those ba­bies stay for at least five days. If they need med­i­ca­tion, like mor­phine, they could be there for six weeks un­til their tiny bod­ies are fully weaned off.

It’s hard to gauge ahead of time whether a baby will need mor­phine or not. The sever­ity of the with­drawal is not nec­es­sar­ily re­lated to the level or dose of a mom’s drug use, pe­di­a­tri­cian Dr. Sandi Seigel says. There are too many other fac­tors to con­sider — like body weight, me­tab­o­lism, etc.

One Fri­day this past March, there were more ba­bies in opi­oid with­drawal in the St. Joe’s NICU than there were rooms to keep them in. Nurses and even the desk clerk take turns rock­ing the tiny swad­dled bun­dles.

For the days or weeks they are there, the ba­bies need to be held al­most con­stantly. It is not high­tech care, but it is hands-on care. They are ir­ri­ta­ble, sen­si­tive to light. This is why bunk rooms — “care by par­ent” rooms, they call them — are pro­vided to par­ents dur­ing the with­drawal pe­riod — so they can be there to hold their ba­bies, and pro­vide skin to skin con­tact and breast­feed­ing.

Even those who stay off­site — and even those who will not be tak­ing their ba­bies home with them — are en­cour­aged to come in each day for as much as that care as they can han­dle.

When the par­ents are un­avail­able — if they leave to get food, for ex­am­ple, or to go to a methadone ap­point­ment — the staff takes over. Nurses take turns hold­ing ba­bies un­til they are calm enough to put in the bassinettes, back in the sparsely dec­o­rated quiet rooms.

But to­day there are five ba­bies, and only four rooms.

“When I started (20 years ago), we’d maybe have one ev­ery six months,” reg­is­tered nurse Ann Pat­ton says, rock­ing one of the ba­bies in her arms.

When she has to put him down to tend to an­other pa­tient, the desk clerk shuf­fles in to take over. Vol­un­teer ‘cud­dlers’ come in to help hold ba­bies when the staff are over­whelmed.

IN CASES where an ap­pre­hen­sion plan is in place, fos­ter par­ents have a more in­volved role than ever be­fore. In the past, if a baby was go­ing to be taken away, the fam­ily would never cross paths with the fos­ter par­ents.

“Be­fore, they’d come in one door and out the other,” Pat­ton says. It was se­cre­tive. Ta­boo. “But now they work to­gether.” Af­ter a baby with NAS goes home, the St. Joe’s clinic fol­lows up closely. There are 63 ba­bies they are still fol­low­ing. Be­cause longer-term ef­fects of opi­oids on ba­bies aren’t to­tally clear, they re­turn for growth and devel­op­ment checks by a pe­di­a­tri­cian at reg­u­lar in­ter­vals: two months, four months, six months, eight months, 12 months and 18 months.

If an is­sue is de­tected in a baby — a speech de­lay or a mo­tor skill de­lay, for ex­am­ple — the clinic helps get the ap­pro­pri­ate ser­vices looped in as soon as pos­si­ble, whether they know if it’s con­nected to the NAS or not.

“Partly just be­ing prag­ma­tists, we may not be able to say why (this is­sue ex­ists as a re­sult of NAS), but we know there’s an is­sue so it’s im­por­tant to iden­tify so they can get fol­low up,” Dr. Seigel says.

“We have some ba­bies who are do­ing quite well. And even those ones with de­lays, it doesn’t mean it’s per­ma­nent,” she says. “It’s pos­si­ble to have a baby (with NAS) and have it be per­fectly fine.”

In to­tal, 30 ba­bies have “grad­u­ated” from the St. Joe’s checkup pro­gram since it launched three years ago. An­other 15 ba­bies stopped com­ing in. None of this is manda­tory, of course. They can’t force peo­ple to come in for ap­point­ments. But most are en­thu­si­as­tic about it — and it of­fers the doc­tors a chance to check in on mom and how she is do­ing as well.

NEXT MONTH, Carter and Ad­ina will go for their fi­nal 18-month checkup.

Ad­ina has now been sober for two years and her blad­der is­sues have sub­sided. She is think­ing about go­ing back to work and is work­ing on get­ting her driver’s li­cence. She and Chris hope to get their own place. Even­tu­ally, she’d like to get off methadone en­tirely. She wants to have more chil­dren and doesn’t want them to go through with­drawal.

Life is bet­ter now than she could have ever imag­ined even three years ago. She is proud, be­cause she knows peo­ple thought she was go­ing to “screw up” and she didn’t. “I’m just so happy hav­ing a clear head,” she says.

As a fam­ily, they are thriv­ing. Even Chris, the guy she says friends saw as a bad in­flu­ence and who no­body ever had faith in. “But he ac­tu­ally saved my life,” she says. “And I saved his.”

The Ma­ter­nity Cen­tre made her feel proud of be­ing on methadone, and get­ting the treat­ment she needed Women who switch to methadone are more likely to have their ba­bies at term and with full birth weights

PHOTOGRAPH BY JOHN RENNISON, THE HAMIL­TON SPEC­TA­TOR

Lisa Nussey is a lo­cal mid­wife who is part of a pro­gram that sends mid­wives out to help vul­ner­a­ble women in any lo­ca­tion where they are com­fort­able.

BARRY GRAY, THE HAMIL­TON SPEC­TA­TOR

Ad­ina, Chris and their baby Carter, who was born with neona­tal ab­sti­nence syn­drome in Oc­to­ber 2015. Ad­ina was on methadone while preg­nant and wor­ried about her baby’s health. But with the help of pro­grams at St. Joe’s and HHS, Carter is now 17 months old and thriv­ing.

CATHIE COWARD, THE HAMIL­TON SPEC­TA­TOR

Lisa Nussey is a lo­cal mid­wife and part of team that will help vul­ner­a­ble women wher­ever they are com­fort­able. Pre­na­tal care can be low on the list of pri­or­i­ties for a woman who does not even have shel­ter.

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