“Now is the time for this report” writes Kana Enomoto of the Substance Abuse and Mental Health Services Administration, in regards to surgeon general Dr. Vivek Murthy’s thorough treatise, Facing Addiction in America. Released last month, it found that more than 289 million prescriptions were written for opioid analgesic pain relievers in 2012. Coinciding with the seemingly ubiquitous prescriptions is rampant misuse. Between 2005 and 2011, opioid-related emergency department visits increased by more than 200 percent. The report reveals that 61% of the 47,055 deaths owing to drug use in 2014 were indebted to opiates, both prescription medication and heroin.
As public health advocates and policy architects coalesce on strategy to combat opiate misuse and mend communities (disproportionately rural) devastated by the opioid crisis, the full scope of its casualties is only now starting to crystallize, namely children. The welfare of children is further jeopardized as adults turn towards heroin in the wake of oxycodone scarcity.
Addicted to the overly-prescribed opiates, some have resorted to heroin, a cheaper but comparable high. The US cracked down on long-acting oxycodone prescriptions in 2010, over a decade after Purdue Pharma began flooding America, especially its rural centers, with OxyContin and disingenuous claims regarding addiction risk and the length of pain relief. Post oxycodone repression, the street value of opioid pain relievers soared while heroin’s lower price tag remains steady and its availability consistent. Rural areas now have an unprecedented heroin problem, proliferating much faster than treatment or strategies can be provided. Heroin overdoses grew five-fold from 2004 to 2014, but more than tripled between 2010 and 2014. Fentanyl, a synthetic opioid up to fifty times stronger than heroin, was responsible for 75% more deaths from 2014-2015, because users misunderstood its potentially lethal potency compared to heroin.
And while parents fall victim to the opioid morass, children are watching.
In 2016, there was example after example of offspring bearing witness to their parents’ opioid use and overdose, and in December, both the Wall Street Journal and the Washington Post published excellent profiles about children orphaned by their parents’ fatal opioid addiction. In West Virginia, nearly an entire generation watched family members succumb to the opioid epidemic. The family structure has been demolished by their loss, and rebuilt with the support of grandparents on the cusp of retirement, and the generosity of extended family members or friends, for minors lucky enough to have such resources available to them. In hard-hit states, foster care systems are exhausted and desperately seeking homes for kids displaced by their parents’ opioid misuse; children who haven’t been removed from these homes may live in food barren squalor, collateral damage in what Charles P. Pierce calls “an almost unspeakably tragic collision between economic disenfranchisement and unbridled corporate profiteering”.
From 1997 to 2012, 13,052 children were admitted to hospitals for opioid poisonings. The occurrences of overdoses increased for every age group, but the most dramatic hikes belonged to 1-4 year-olds and late teens, the latter likely self-inflicted or the result of dangerously combining other substances with opioids.
This month, JAMA published its research on the incidence of neonatal abstinence syndrome (NAS), which rose nearly five-fold between 2000 and 2012 (21,732 newborns diagnosed in 2012). NAS is the consequence of in utero exposure to opioids, when the infant displays postnatal withdrawal symptoms. By 2012, it was estimated that every 25 minutes, an infant suffering opioid withdrawal is born, translating to 5.8 newborns for every 1,000 hospital births (though as high as 18.9 births in rural areas). 81.5% of infants diagnosed with NAS were more likely to be insured by Medicaid than private insurance; the Medicaid patient population is more likely to receive opioid prescriptions and at a higher dose for longer time periods than the private patient population. The states with the highest incidence of NAS are concurrently the top opioid pain reliever prescribing states.
Newborns born with NAS typically have longer hospitalizations (an average of 16.9 days compared to 2.1 days for healthy babies) due to the litany of complications from withdrawal, which include seizures, low birth weight, difficulty feeding, and respiratory issues. In 2009, this accounted for $730 million in hospital expenditures, but in 2012, the total ballooned to $1.5 billion. Hospitals are under-resourced, straining to provide the attention and care needed by the swell of infants born with NAS.
Opioid misuse is now the most common explanation for pregnant women seeking treatment for illicit narcotics. However, populations most vulnerable to the opioid crisis have the most limited access to treatment. Quitting opioid use without the assistance of drugs is very dangerous for pregnant women and their fetus- it can cause miscarriage, premature labor, fetal distress, and a higher chance of an overdose should the mother return to using opioids. But there is a promising solution:
MAT (medication-assisted treatment) is the widely recommended method for assisting perinatal women misusing opioids. MAT is a portmanteau of medication (either methadone, buprenorphine, or naltrexone) and therapy (counseling or behavioral treatment and support). The Substance Abuse and Mental Health Services Administration describes medication-assisted treatment as both “clinically effective” and “greatly underused”.
Pregnant opioid users in rural communities suffer the “extreme paucity” of MAT options; there are very few long-term, residential, or day facility options for opioid dependency. 23% of rural counties are considered to be in “persistent-poverty” and 25% of working adults over 25 in these areas have an income under the federal poverty line. Therefore, many pregnant women in need of MAT don’t have cars, their community provides very limited public transportation at best and, should they be employed, most are hourly earners who don’t have the luxury of choosing treatment at the expense of paid work.
To make matters worse, buprenorphine distribution is a bureaucratic quagmire. Unlike the unscrupulous amounts of OxyContin prescribed before 2010, physicians must be in possession of a special waiver to prescribe buprenorphine (up to 275 patients, after a year of treating 30) and, despite the need to the contrary, they commonly practice in more population dense areas of the country. Waiver-carrying practitioners in rural pockets (only 1.3 of prescribers) are more likely to have exhausted their limit of buprenorphine prescriptions, and doctors who wish to adopt MAT within their practice are frequently met with barriers– funding, program requirements, or lack of support. The wait list for methadone clinics is years long in some cases, and at least 34 states have restricted quantity limits for buprenorphine, if not lifetime limits.
Every state, provider, and system has it’s own way of deciding and providing opioid treatment, so the enactment of MAT is far from seamless or uniform; Buprenorphine prescribed by one doctor may be discouraged by other treatment providers. In some areas, child welfare agencies could use a MAT positive toxicology report as grounds for child removal, frightening parents away from treatment. Some states criminalize drug misuse during pregnancy, and pregnant women may fear being prosecuted or losing custody of their child, and forgo treatment or attempt to abruptly discontinue use, both of which are dangerous to the mother and fetus. The treatment system has presented parents with an impossible choice; their health or their family.
The best protection for children against the opioid scourge is to offer accessible, consistent, and affordable treatment for their guardians. When surgeon general Murthy writes “we also have proven interventions for treating substance use disorders, often involving a combination of medication, counseling, and social support” he is describing MAT. Real-world proof exists: both the CHARM collaborative in Vermont and Hope on Haven Hill in New Hampshire have received national recognition for providing new mothers and infants with coordinated care using medication-assisted treatment. New Mexico, West Virginia, Wyoming, and Virginia are exploring teleheath therapy and teleconsultion for opioid users enrolled in MAT programs, devoid of nearby facilities.
This month, Obama signed the 21st Century Cures Act, which will dedicate $1 billion to opioid misuse prevention. Though it does little for the current casualties of the opioid epidemic, it offers hope to future generations of families affected by the crisis.