ADDI CTED Newborns struggle with

the legacy of opioids.

AT BIRTH
BY COOPER LEVEY-BAKER

A LL BABIES CRY, but the cry of a child

born with neonatal abstinence syndrome
is different. High-pitched and coming in
desperate waves, the cry envelops the newborn
as it goes through seizures, the baby’s muscles
shaking and clenching uncontrollably.
“It is a cry that screams pain,” says Katie
Powers, a nurse at Mothers of Manatee Memo-
rial, known as MOMM’s Place, an outpatient
education center for families and babies at
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Manatee Memorial Hospital in Bradenton.
The sound can be traumatic—so traumatic,
Powers says, that it causes nurses at Manatee
Memorial to rotate shifts more frequently
when caring for multiple babies afflicted with
neonatal abstinence syndrome (commonly
Newborns exposed to opiates in the
womb feel the pain of withdrawal known as NAS). “Nurses can’t do it two days
immediately after birth. in a row,” Powers says.

42 43
 The baby’s struggles are numerous.
“Their oral facial muscles are not coordi- Morgan Carle’s son, Ryder, is experiencing
developmental delays because of NAS and
nated enough to transfer milk, so they’re other factors.
difficult to feed,” says Powers, and their

S
digestive systems are “a mess.” Other
symptoms include diarrhea, awful diaper
rashes, fevers, stuffy noses and breathing
problems. NAS babies can’t be consoled,
they can’t eat and they can’t sleep.
NAS occurs when a newborn experiences
withdrawal from an opiate that he or she
was exposed to while in the womb. Morgan
Carle’s son, Ryder, was born with NAS at
Johns Hopkins All Children's Hospital
in St. Petersburg three years ago. Carle,
now 36 and living in Sarasota, was using
intravenous drugs when she found out
she was pregnant. She stopped when a
doctor prescribed methadone for her
as a substitute, but she still used Xanax
recreationally and drank on occasion.
“It’s so shameful,” Carle says.
After Ryder was born, he spent a month
in the hospital’s neonatal intensive care
unit, where he received morphine and
two blood transfusions. “It was horrible
watching him in the hospital coming off of
the drugs,” Carle says. “Talk about heart-
breaking, to see this poor little innocent
baby that had nothing to do with it, and
it’s all your fault.”
INCE AMERICA’S OPIOID EPIDEMIC began and oftentimes, the studies and
to explode two decades ago, more than 400,000 the data sources don’t have all
Americans have died from opioid overdoses. those variables,” Ko says.
That makes drug overdoses the leading cause of death Medical practitioners have
for people under 50 today. treatments to ease the syndrome.
The first wave of the crisis was fueled by what the When the baby is born, morphine
federal government calls misleading marketing practices typically lessens NAS symptoms
by opioid manufacturers that downplayed the risk of and the child is slowly weaned
addiction, as well as doctors who overprescribed the from the drug over the course
medications, either knowingly or unknowingly. Overall, of three to four weeks. But ad-
the epidemic costs the United States an estimated $504 dressing NAS also starts well
billion each year—2.8 percent of the nation’s entire gross before birth. A mother quitting
domestic product—and thousands of cities, counties, opiates cold turkey while preg-
states, tribes, hospitals and other nant can lead to miscarriages
agencies, including some in Sarasota
and Manatee counties, are suing
“It was and fetal distress, so pregnant
addicts are usually prescribed
opioid makers to recoup what the horrible either methadone or buprenor-
epidemic has cost them. phine, two other opioids. Those
But as those lawsuits play out in
watching him drugs alleviate the pain caused
distant courtrooms, stories of human in the hospital by withdrawal without delivering
suffering continue to accumulate euphoria.
here at home. As the number of coming off of The nonprofit Operation PAR
overdoses has increased, so has the the drugs.” runs nine methadone clinics be-
number of babies born suffering from tween Spring Hill and Fort Myers.
withdrawal, the pain of addiction Its Sarasota and Bradenton loca-
cascading from one generation to the next. Nationwide, tions have more than 1,000 active
the number of women giving birth while on some sort patients. Between them, those
of opioid more than quadrupled between 1999 and 2014, two clinics treated 53 women
hitting a rate of 6.5 per every 1,000 hospital deliveries. who gave birth last year.
(In comparison, the rate of children born with fetal Operation PAR’s Sarasota
alcohol syndrome in America ranges from 0.5 to 2 per branch on South Tamiami Trail
1,000 births.) The number of NAS cases in America opens at 5:30 a.m. on weekdays and
increased nearly fourfold between 2000 and 2012. 6:30 a.m. on weekends. By the time
The problem is especially acute in Florida, where the doors are unlocked, dozens of
nearly 6,000 babies were born with the condition between patients have lined up outside the
2014 and 2017, and Sarasota and Manatee counties have clinic to receive treatment before
some of the state’s highest rates of NAS. In the last three Dr. Jean Ko, an epidemiologist with the Centers for they go to work. Nearly all Operation PAR patients are

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years alone, Sarasota Memorial Hospital has treated Disease Control and Prevention, says understanding
349 newborns with NAS, while Manatee Memorial has why the crisis is worse in some areas than others is
cared for another 203. complicated by a lack of consistent data. Up until just
this year, states were using different definitions of NAS
and different codes to record instances of the syndrome.
taking liquid methadone every day, as well as attending
counseling sessions with Operation PAR professionals.
Jon Essenburg, an Operation PAR vice president,
says opiates like heroin or prescription pills provide
a “rollercoaster” effect, a high followed by pain, while

DELIVERY DATA
Sarasota and Manatee
counties have some of
the state’s highest rates
of babies born with
neonatal abstinence
syndrome. Here are the
number of newborns
with NAS per every
10,000 births in 2017:
The long-term prognosis for babies born with NAS is
also unclear, Ko says. One study in Tennessee found that
children born with NAS were more likely to experience
FLORIDA
developmental delays and speech or language impair-
67.2 ment when they entered school. But children with NAS
SARASOTA COUNTY are also more likely to experience other traumas early
212.8 in life and are often raised in chaotic environments by
parents struggling with addiction. Singling out NAS as
MANATEE COUNTY the sole cause of later problems isn’t easy.
155.4 “It’s important to consider other substances an infant
might have been exposed to and their environment;
methadone and buprenorphine, when taken daily,
create a “steady state,” during which users are more
able to remain sober and even-keeled.
Carle, Ryder’s mother, first used drugs at 14, with
her mother, who is now deceased. “I grew up in that
environment where that was the norm,” she says. When
she found out she was pregnant at age 32, she was using
Dilaudid. Her doctor switched her to methadone to
stabilize her and she moved to a rehab facility in Largo.
Methadone helped keep Carle sober, but she says her
dose still left her feeling “out of it.” She stayed on the

44 45

drug for two years after giving birth, before deciding
to kick it completely.
Methadone isn’t a cure-all for NAS. In roughly seven
out of 10 cases, a child born to an Operation PAR patient
using methadone will still spend time in an intensive
care unit being weaned from opiates with morphine,
which deadens the pain.
Opiate addiction includes two distinct components,
Essenburg says: a physiological dependence on the
substance, as well as a psychological compulsion. NAS
babies are born with the physical symptoms, but have no
mental fixation on drugs. That means that once they’ve
been weaned in their first few weeks, they shouldn’t be
any more likely than they otherwise would be to abuse
drugs when they grow up. But addiction is often passed
down from generation to generation through genes.
Studies show that the heritability of alcohol dependence
ranges from 50 to 60 percent, while the heritability of
illicit drug use runs from 45 to 79 percent. Operation
PAR treats whole families addicted to opiates: seniors,
their children and their children’s children.
For NAS babies, “the susceptibility to opiate addiction
Dr. Washington
is probably going to be there,” Essenburg says, “but it’s not
Hill, below,
at right, says a guarantee.” Dozens of variables affect how pregnancy
Sarasota health
care providers
plays out for an addicted pregnant woman, including
substances besides opiates that they may abuse and how
have “come
a long way”
early they seek prenatal care.
Dr. Washington Hill is a senior obstetrics and gyne-
in caring for
addicts. cology physician with CenterPlace Health, a nonprofit
46
center that serves low-income communities. He says
complicating health factors include obesity, sexually
transmitted diseases, heart disease, poor nutrition
and hepatitis C, and the women might be homeless or
incarcerated. The Sarasota County jail housed 83 preg-
nant women last year, 12 of whom were taking either
methadone or buprenorphine.
Hill first noticed an uptick in the number of addicted
patients five years ago. “Many of these patients told us
they were started on opiates for legitimate reasons,”
Hill says. A car accident led to an injured back, which
led to a prescription for pills. Years later, the women
found themselves still hooked. “You hear many stories
like that,” he says, “and I believe them.”
In the past, according to Hill, there was little com-
munication between maternal physicians, Operation
PAR and the many nonprofits and agencies that interact
with addicted women, like Healthy Start, First Step and
Planned Parenthood. Hill helped spearhead the creation
of Addiction Support and Pregnancy (known as ASAP),
a task force that tries to coordinate care for pregnant
addicts and babies with NAS and other risky conditions.
Steps as simple as inviting pregnant addicts to tour the
labor and delivery and newborn intensive care units at
Sarasota Memorial help put the women at ease and keep
them on track, he says. The hospital also offers a support
group for pregnant women struggling with addiction
that brings in around six people every Wednesday.
That sort of outreach can help bridge the gap between
caregivers and addicts, who often feel a
crushing sense of guilt about having used
drugs while pregnant. For Carle, seeing
her son, Ryder, suffer from NAS was dis-
tressing enough. The shame she felt made
the experience all the more painful. “The
guilt is just insane,” she says.
NAS mothers also feel the sting of nurses
and doctors judging them. As Ryder was
being treated, Carle visited him four times
every week for eight hours at a time. She
says nurses made snide remarks when
she struggled to change a diaper and fre-
quently brought up her past drug use. “It
took all my courage just to go there and
see my own child,” Carle says.
Overcoming “implicit bias” is a major
hurdle in treating pregnant addicts and
mothers, says Dr. Eddy Regnier, a clinical
psychologist. Americans are inundated
with ugly portrayals of racial and eth-
nic groups and poor people, images that
affect how we perceive others, whether
we’re conscious of it or not. Meanwhile,
minorities often hear stories from their
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parents and grandparents about how the
medical establishment mistreated them in
the past, which instills a fear and mistrust
of doctors and nurses. Addicted women are
the science of
opiate addiction
HOW OPIATES WORK
When opiates (like heroin) and
also often victims of abuse at the hands of men. When opioids (synthetic drugs, like
they seek care, they must turn to a doctor, who is still OxyContin) enter the body, they
more likely to be male than not. travel through the bloodstream
“Implicit bias is all that negative stuff playing in the to the brain, where they attach
background, and you’re not even aware of it,” Regnier to receptors on certain cells.
says. The medical establishment has done a poor job This causes the brain to release
of teaching nurses and doctors about bias and how to dopamine, flooding the user with
combat it. “The only way to change the outcome is to pleasure.
engage doctors to discuss their feelings,” he says.
Addiction is also too often seen as a personal choice, THE ONSET OF ADDICTION
rather than as a physiological condition that requires When someone uses opiates or
treatment. “If someone has a fever, we don’t talk about opioids, his or her brain creates
their morality,” Regnier says. intense associations between
Powers, the Manatee Memorial nurse, says it takes the pleasure from the drugs
a long time to convince NAS moms that she and other and the person’s circumstances
nurses aren’t looking down at them. “Judging you is and environment, causing users
not in my job description,” she tells to seek more drugs to recreate
them. “Our job is to care for you and that experience. But as drug
care for your baby.” “Clinics treat use increases over time, opioid
According to Hill, increased collabo-
ration within the health care, addiction
whole families receptors in the brain become less
responsive, and the brain begins to
treatment and criminal justice worlds addicted to function properly only when opiates
is making a difference. “I don’t think are in the user’s system.
there’s any question we’re heading in
opiates: seniors,
the right direction,” Hill says. In 2016, their children WHAT IS WITHDRAWAL?
4 percent of babies born at Manatee When an opiate user quits
Memorial and 3.7 percent of babies
and their taking drugs, the brain releases
born at Sarasota Memorial suffered children’s excessive amounts of the chemical
from NAS. Last year, those numbers noradrenaline, which creates the
dipped to 3.1 percent at both hospitals. children.” flu-like symptoms associated with
The tide appears to be turning. Slowly. withdrawal. People going through
Carle’s son, Ryder, is now 3. He is experiencing de- withdrawal suffer from severe
velopmental speech delays and suffers from gastropa- pain, fevers, jitters, anxiety, muscle
resis, a stomach condition that makes it difficult to eat. cramps, nausea and diarrhea.
After leaving the neonatal intensive care unit at All
Children’s, he was placed in a foster home, while Carle HOW METHADONE HELPS
worked through a Department of Children and Families Methadone is a synthetic opioid
case plan. She was eventually reunited with him, but first developed in Germany during
relapsed last year and was arrested for battery against World War II and first tested as a
a friend. “Addiction is a horrible, horrible thing,” Carle treatment for opiate addiction in
says. “It destroys families.” Sentenced to probation, she America in the 1950s. Methadone
regained custody of Ryder from a foster home this May. acts on the same opioid receptors
Ryder now attends a specialized daycare and receives as heroin, but unlike fast-acting
in-home visits from therapists at The Florida Center opiates, it has what researchers
for Early Childhood. According to Carle, Ryder may call a “timed-release” mechanism.
eventually catch up developmentally with other kids, When taken daily, methadone
but there’s no crystal-clear prognosis. He’s talkative, suppresses withdrawal symptoms
outgoing and fun. “He’s a joy to be around,” Carle says. while not producing a high.
Carle, meanwhile, rides the bus to work at Lucky’s (Buprenorphone is also prescribed
Market and attends 12-step meetings. to some opiate addicts. It works
“There have been some times when I wanted to use,” similarly to methadone but has a
she says, “but I don’t want to lose Ryder ever again, so “ceiling effect” that makes it safer
that just can’t happen.” for some patients.)