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PREGNANT WITH HOPE
Securely swaddled in white blankets, one-day-old Aubrianna snoozed silently against her mother’s chest.
Maria Sandoval, 24, held her newborn close as she lay in her hospital bed. Her voice was soft and gentle as she described her rough, tumultuous history with opioid addiction.
If Sandoval hadn’t found a path toward recovery, Aubrianna might not be nestled next to her mother- let alone have the middle name revealing Sandoval’s new outlook on life: Hope.
ADDICTION SUCKED HER IN
Sandoval started hanging out with the “wrong crowd” while she was growing up in Monte Vista, a rural town in Colorado’s San Luis Valley, with a population just shy of 5,000.
“It’s small. There’s not really much to do,” Sandoval said. “That’s why everyone’s out getting high, stealing from the stores to get high, but once you get clean there is so much more to that.”
The San Luis Valley, as well as towns in southeastern Colorado and the central mountains, were among the rural areas hardest hit as the state’s opioid and heroin overdose death rate nearly tripled between 2001 and 2015, according to data from the Colorado Department of Public Health and Environment.
Pueblo, Adams, and Denver Counties experienced the greatest increase in overdose deaths among urban areas.
As Sandoval cradled her sleeping infant, she recounted how her three-year heroin binge began.
It started with pills, she said.
“And I just couldn’t stop.”
She was instantly hooked on Percocet and eventually switched over to heroin.
The drug snatched three years from her life.
“Your body just aches, and you do not feel good. You withdraw. You’re hot. You’re cold. You’re angry. You do anything to get money,” she remembered. “I’d be stealing from the stores – stealing from people trying to get money.”
Once she was so high, she loaned her car to a friend looking for a fix. “They completely wrecked it…so now I don’t have my own car.”
“It’s awful,” she said.
When she started gaining weight and feeling ill, Sandoval wondered whether she had an infection or was experiencing withdrawal.
Instead, she discovered she was four-months pregnant.
“I cried for days,” she recalled.
She had already seen heroin’s ugly effects on an innocent life. She was in the delivery room when a cousin gave birth to a little boy, she remembered.
“He just kept crying and crying, shaking, you know – there wasn’t anything anyone could do.”
Babies born to opioid-addicted mothers are at risk of experiencing serious withdrawal symptoms like shaking, seizures, trouble feeding, low birth weight, miscarriage or premature birth.
WHAT THE DATA SHOWS
Colorado does not consistently and uniformly track where and how often drug-addicted mothers give birth to babies who suffer from withdrawal symptoms related to opioid use, also known as Neonatal Abstinence Syndrome. However, at the request of Rocky Mountain PBS, the Colorado Hospital Association evaluated five years of medical codes from birth records at the organization’s one hundred hospitals statewide.
According to their data, the number of newborns experiencing opioid-related withdrawal symptoms increased nearly two and a half times between 2011 and 2015.
There were 109 diagnosed cases in 2011. In 2014, the number of documented cases increased to 221. Medical coding methods changed in 2015, but according to annualized data compiled by CHA, the number of cases increased to 268 that year.
The numbers are based on specific diagnosis codes. Depending on a doctor's evaluation of a patient, it is possible some babies around the state have gone undiagnosed and uncounted.
Nationally, the problem is growing more rapidly in rural areas, according to a recent study conducted by the University of Michigan. Researchers found the number of rural babies experiencing opioid-related withdrawal symptoms after birth increased by more than six times during a recent span of 10 years compared to nearly three and a half times for urban babies.
THE DOCTOR AND THE ROAD TO RECOVERY
Sandoval said she was terrified to tell the doctor about her addiction. But she knew she couldn’t get sober by herself.
“I was scared to get judged,” she revealed. “But after I told [the doctor], you know, she helped me with whatever she could.”
Sandoval was determined to climb out of the depths of her drug-addicted life.
“I had a long talk with my mom, and I had to get help somehow because it’s not [Aubrianna’s] fault, you know? She didn’t ask to be conceived to a mother that’s addicted to heroin, so I had to do anything I could to get help,” Sandoval said.
DR. BARBARA TROY
Dr. Barbara Troy, a jovial obstetrician with a perpetual grin, sees many pregnant addicts at her clinic in rural Alamosa, including Maria Sandoval.
When Troy arrived in town in 2014, she immediately recognized an opioid abuse problem in the community and very few medical options for treatment.
“You see all kinds of needles, and you look around and you see all kinds of addicts. They are obvious,” said Troy, eyes widening under her glasses.
Troy previously specialized in addiction treatment as a doctor in Espanola, New Mexico between 2009 and 2014, but she didn’t expect she’d be using her expertise so quickly upon her arrival in southern Colorado.
Troy immediately joined a newly formed neonatal substance abuse task force to help bring attention to the growing issue and discovered her enhanced training and special waiver to prescribe special medication for pregnant addicts would be an important step for helping them have pregnancies with fewer complications.
“Any time you have even one mom delivering and not being able to take her baby home…that’s a problem.”
The American College of Obstetricians and Gynecologists recommends only two treatments for pregnant addicts: methadone – a liquid which is usually administered in a clinic – and buprenorphine, an under-the-tongue film or tablet, which requires a doctor to have special training in order to prescribe it.
Dr. Troy launched the community’s only methadone clinic in 2015. It is one of 19 throughout the state.
According to the federal government’s Substance Abuse and Mental Health Services Administration, methadone has been around for decades and helps prevent withdrawal symptoms and “helps pregnant women better manage their addiction while avoiding health risks to both mother and baby.”
Buprenorphine is a newer medication-assisted treatment that can cut an addict’s cravings while reducing withdrawal symptoms and the length of a hospital stay for newborns.
According to a 2010 National Institutes of Health study comparing the two treatments, “buprenorphine resulted in similar maternal and fetal outcomes, yet had lower severity of [Neonatal Abstinence Syndrome] symptoms, thus requiring less medication and less time in the hospital for their babies.”
NOT MANY RURAL DOCTORS
Dr. Troy is the only doctor within at least 50 miles of her rural community with training and proper certification to treat patients with buprenorphine, according to federal records. Another nearby doctor with the training and certification left town in early January.
During her first year working for Valley-Wide Health Systems in Alamosa, Troy was only permitted to assist thirty patients, in accordance with the law.
“I went from zero to thirty quickly,” Troy said. “The goal was I wanted to take care of these mommies and babies. That was my main goal – was to protect the babies because when you protect a baby in utero, you’re protecting them for a lifetime – and a lifetime of public assistance if you don’t do it.”
Troy also often treats a baby’s father in an effort to keep families intact.
Troy started treating Sandoval over the summer. She said she often asks her patients how long they’ve been using opioids, in order to determine how long their road to recovery may last.
The process isn’t easy, she said. It is hard work.
“It would be like a diabetic eating chocolate cake. If you’ve been eating chocolate cake every day, and now I’m saying, ‘No chocolate cake,’ you know, it’ll take you awhile to get off the chocolate cake. Can you do it? Sure you can, but it’s a struggle.”
Troy said Sandoval was required to see her on a weekly basis and enter counseling for her addiction.
“It was hard,” said Sandoval. “Nothing is ever easy, but if you have the right support system, you get the help you need. I think it’s possible.”
When Aubrianna was born, the baby suffered minimal withdrawal symptoms.
“The baby has done very well thanks to [Sandoval] just stepping up to the plate after some struggles and doing what she needed to do to get well – going to her counseling and moving toward sobriety,” said Troy.
Sandoval had to cut contact with a variety of friends and family as part of her recovery.
“A lot of people were still trying to get me to use,” said Sandoval, “and just being around it tempts you to want to use even though you don’t want to. So it’s better to stay away and surround yourself with people who want to help you.”
NOT ENOUGH PROVIDERS
Dr. Kathryn Wells, a child abuse pediatrician and the co-chair of a Colorado task force on substance-exposed infants, said there are not enough care providers in the state to address the needs of every pregnant patient.
Currently, according to SAMHSA, nearly half of the 64 counties in Colorado do not have a medical provider with training and proper certification to legally prescribe buprenorphine.
“I know the state is working really hard and the task force that I'm involved in is working really hard to look at how do we increase the number of doctors that can prescribe this drug,” said Wells, who serves as the Medical Director of Denver Health Clinic at the Family Crisis Center.
This summer, in accordance with the Comprehensive Addiction and Recovery Act of 2016, the federal government increased the number of patients from 100 to 275 whom a specially-trained physician can treat.
Nurse Practitioners and Physicians Assistants with proper training and licensing may now also be eligible to prescribe the drug as a result of the law, which took effect in July 2016.
UNIVERSITY OF COLORADO GRANT
The University of Colorado Department of Family Medicine recently received grant funding for a three-year project that will help train additional medical providers to use buprenorphine in rural areas of the state.
According to Linda Zittleman, the High Plains Research Network Associate Director at CU, the department received funding in 2016 from the Agency for Healthcare Research and Quality, AHRQ.
The project, which will recruit 40 primary care practices for participation from rural eastern Colorado and in the San Luis Valley, will compare and examine the effectiveness of two training styles: web-based education, and in-person training.
Physicians, physician assistants and nurse practitioners will receive the training that will eventually enable them to receive the appropriate certificate to prescribe buprenorphine to addicts in their regions.
A WOMAN’S RIGHTS
Despite the demand for her services, Troy said many addicts do not seek help until very late in their pregnancies. Sometimes, they’re unaware of their pregnancy, but other times, they are afraid of the legal implications when they admit to using drugs while pregnant.
“They’re like, ‘Oh you’re going to report me. Are you going to have me arrested? Are you going to give my baby away?’ Their biggest fear is that they’re not going to get to keep their babies.,” she said. “[Many pregnant addicts] don’t understand that in medical care, that’s not our job. Our job is to provide health care.”
Wells helped make sure pregnant addicts seeking prenatal care would receive protection from criminal prosecution by advocating for a Colorado law that went into effect in 2012.
“When [an addict] shares this information with a health care provider for the purpose of getting prenatal care or determining if she is pregnant, then that is not going to be able to be used for a criminal prosecution,” said Wells.
She said a woman will not automatically have her child removed from the home simply because the mother used drugs during the pregnancy.
“Child welfare is going to make a decision based on safety and risk on each individual situation,” she said. “At least in my experience, just because a baby was exposed prenatally does not equal a removal. It equals an assessment to what needs that child in that family might have and how can it be assured that that child is safe in that environment.”
Wells’ task force is working with a select group of hospitals to develop a list of best practices when tracking and treating substance-exposed infants. She said more public awareness about addiction will help address the statewide problem.
“We’re talking about a problem that's one hundred percent preventable. One hundred percent," she said. "Every single one of these babies that has to go through this would be one hundred percent preventable if we could address the issue around addiction."
According to Colorado’s Department of Human Services, the state will start implementing additional measures this July in an effort to better track specific drugs and their effects on babies and children.
Colorado Counties with Buprenorphine-Trained Doctors
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