For the past month, he has been lying in a bassinet in a Hamilton hospital’s neonatal intensive care unit.
Nurses feed him droplets of morphine and closely monitor him for fever, tremors, rashes and sweat gathering on his neck and brow. By now, they are used to his frenetic, high-pitched cries, an unrelenting and inconsolable wail that indicates a baby going through withdrawal.
Nearby, four other newborns — a shocking one-quarter of the nursery’s occupants — are also coming off the narcotic drugs their mothers took while pregnant.
It is both a distressing and a familiar sight here at St. Joseph’s Healthcare Hamilton and in neonatal intensive care units across the province.
In the past five years, there has been a staggering increase in the number of babies born dependent on prescription painkillers.
The incidence of neonatal abstinence syndrome, or NAS — in which a baby is born addicted — has skyrocketed alongside the epidemic use of legitimate and illicit opioids, particularly drugs that contain oxycodone, the active ingredient in OxyContin and its replacement, OxyNeo.
In 2003-04, Ontario tracked 171 babies born with NAS. In 2010-11, there were 654 — nearly a fourfold increase.
Experts say that with Ontario having the highest narcotic use in Canada and among the highest in the world, the tide of addicted babies is in no way abating
“This is significant,” says David Knoppert, a neonatal pharmacist at London Health Sciences Centre who remembers seeing only one or two babies with NAS in 17 years prior to 2006. Now, the hospital’s nursery cares for about 25 infants with opioid withdrawal each year.
“All of a sudden it started taking off. The numbers just went up exponentially.”
Part of the concern — in addition to the unprecedented numbers of tiny victims who face the pain of withdrawal in the hours and days after birth — is that addicted babies take up beds in high-tech nurseries and tie up healthcare dollars. The average length of stay for a baby with NAS is 15 days, though some need hospital care for up to two months.
Last fall, a provincial task force convened to tackle the growing problem. The resulting guidelines and standards for diagnosing and treating babies with NAS are among the first in North America.
In many cases — such as Levi’s — these infants are born addicted to methadone, the treatment their mothers sought to better protect themselves and their babies during pregnancy.
That Levi is here in a Hamilton nursery, relatively healthy and happy, is the best possible outcome given what might have been.
Up until a month before his birth, his mother, Keri, was selling sex to pay for her and her partner’s addiction to opioids.
She and Robert favoured hydromorphone, a prescription narcotic similar to morphine, which sells on Hamilton streets for about $20 a pill. Together, they would prepare and inject between 20 to 30 pills a day, an expensive $400-a-day habit. They were so fearful of withdrawal that they tried to stay ahead of their addiction.
“It was very rare we would go to bed without money for the next day or pills for the next day,” says Keri, 31, who has spent 10 years addicted to the drugs.
She says it is a life she never wanted. That it was childhood trauma — her mother was stabbed to death by her uncle — followed by years of neglect, a violent rape and the hard knocks of living on the street that caused the spiral into addiction.
The couple found out Keri was pregnant last November. Even that wasn’t enough for either of them to stop injecting drugs, something Keri says they only did to stave off the horrors of withdrawal.
“It was always tomorrow we are going to get help, but tomorrow never came,” she says. “We were stuck in a viscous cycle. I was in a pretty bad place.”
On April 23, a festering infection forced Keri to be taken by ambulance to St. Joseph’s emergency department. There, registered social worker Jodie Pereira arranged for her to undergo medical detox, the first step towards getting clean.
Pereira says it is important hospitals and community programs treat opioid addiction as a medical condition. This, she says, encourages women to seek help during pregnancy — the key to getting the best outcome for mom and baby.
The synthetic opioid methadone is the gold-standard treatment. Studies have shown it is the safest approach even though pregnant women who transition to the long-acting drug are just as likely to have babies with NAS.
The fear for women who don’t get methadone treatment is that a sudden withdrawal of opioids increases their risk of miscarriage and premature labour and can cause their unborn baby potentially fatal distress. Women on methadone are also more likely to comply with prenatal care and to focus on their own health, rather than on how to get their next illicit fix.
In Pereira’s experience, many women who become addicted to opioids start off with a legitimate prescription for the painkillers, perhaps for chronic pain or injuries suffered in a car accident. The highly addictive nature of the drugs means pain control can quickly turn to dependence.
“They could start on pain-management, then have to supplement their dose by illicit purchasing, then move to methadone for the safety of their baby,” says Pereira. “Some of these women cycle through all three dimensions throughout their pregnancy.”
Doctors and nurses report seeing pregnant women of all ages and all social and economic backgrounds addicted to opioids.
And despite growing awareness of the issue, the stigma of drug addiction while pregnant remains a powerful obstacle preventing women from seeking help, says Debbie Bang, executive director of Womankind Addiction Services at St. Joseph’s Healthcare Hamilton.
She says the shame attached to women who smoke cigarettes or drink alcohol while pregnant is hugely magnified for those who use drugs.
“If you are using opioids or any other illicit drug, you are going to go underground,” she says. “You are not accepted by people.
“The reality is it may have been a very innocent initiation. You may not have intended to get pregnant and here you are in a situation where you are the leper of society.”
Keri says this is exactly why she didn’t seek medical care sooner during her pregnancy.
“I was afraid of being judged — my past experiences in hospitals have been pretty bad,” she says, recalling the time a nurse called her “junkie” to her face.
The fear of withdrawal or being “dope sick” also kept her away from treatment.
“It’s like having the flu times 20,” she says. “The pain in your bones is the worst . . . the pain in your legs is so bad you want to cut them off. You are sick to your stomach, you can’t eat, you sweat . . . every bad feeling you can possibly imagine you have from opioid withdrawal.”
It was Pereira — the co-chair of the 2011 provincial task force on NAS — who convinced Keri that medical detox and methadone treatment was her way off the street and the best path to take should she want to parent her baby.
Keri has been clean since the April 23 visit to the emergency department. Even though she was getting good care — and taking better care of herself — Levi was born prematurely by Caesarian section on May 21. He weighed just four pounds, six ounces.
Because Keri had connected with the hospital, pediatricians were aware they needed to monitor Levi for signs of NAS. With methadone, addicted babies may not have withdrawal symptoms until 120 hours — and even up to four weeks — after birth.
Doctors know how to treat babies going through opioid withdrawal with morphine and other drugs. In some mild cases, swaddling and cuddling babies and keeping them in quiet, darkened rooms is enough to ease the symptoms of withdrawal, says Knoppert of the London Health Sciences Centre.
Unrecognized, NAS can be cause life-threatening episodes, such as seizures.
The 2011 task force on NAS, which was assembled by the Provincial Council for Maternal and Child Health, has created a webinar to train physicians and other healthcare workers throughout Ontario on how to diagnose and treat the condition.
Many northern communities are struggling with opioid addiction. Diagnosis, treatment and care for addicted mothers and babies is much harder in regions with fewer healthcare resources.
The task force issued 15 clinical practice guidelines and eight system-wide recommendations. Among them is the proposal to routinely screen all women of child-bearing age for opioids and other drugs and non-medicinal substances. The group of experts also suggested more contraception counselling for women known to be either using or abusing opioids, including methadone.
Ontario Health Minister Deb Matthews says NAS is on the ministry’s radar and calls it a “very, very important issue” for the province.
An expert working group on narcotic addiction established by Matthews in March, which completed its role in May, raised the issue of NAS and opioid-addicted pregnant women.
“This was an area they took a good hard look at and gave us some good advice on,” Matthews says.
Dr. Alice Ordean, medical director of the Toronto Centre for Substance Use in Pregnancy, wants people to know that NAS exists largely because doctors and women are doing the right thing by transitioning from harmful opioid use to methadone treatment.
“NAS is a medical complication of that harm-reduction approach,” says Ordean, who is also an assistant professor in the department of family and community medicine at Toronto’s St. Joseph’s Health Centre.
“It exists because of a harm-reduction model to get women through pregnancy. And if there was no safe pregnancy, there would be no baby in the end.”
Levi will remain in the neonatal intensive care unit for a few more weeks. He still needs to be weaned off morphine before going home.
Keri, too, has a plan. She must complete a five-week addiction treatment program, which starts on Monday — a requirement of the Children’s Aid Society for her to parent Levi. Robert also has to complete a 10-week, half-day program.
Since Levi’s birth, the couple has visited him every day in hospital. They feed him, dress him, cradle him and rock him to sleep.
Keri calls her son, who she hopes will have Robert’s hazel eyes, her saviour.
She has pledged to herself that she will never turn back to her addiction.
“We weren’t living life before, it was a pathetic existence,” she says. “Now, we have every reason in the world to be happy.
“We just want to live life, be a family and live life. It’s what we both have always wanted.”
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