This story, originally published by the Bristol Herald Courier, appeared Sept. 9, 2017. Copyright 2017 Bristol Herald Courier.
KNOXVILLE, Tenn. — Babies of opioid-addicted women are no longer sentenced to endure the anguish of overcoming their mother’s mistakes, thanks in large part to the pioneering work of an East Tennessee physician.
Dr. Craig Towers, a high-risk obstetrician at the University of Tennessee Medical Center in Knoxville, is shattering the accepted standard that a pregnant woman addicted to opioids should remain on monitored replacement therapy for the safety of her unborn baby.
Since the 1970s, the standard of care for pregnant addicts has been to substitute methadone for whatever drug the woman was taking — in order to avoid exposing the baby to potential trauma or death. Such monitored replacement therapy nearly always damned those newborns to weeks of withdrawal symptoms and accompanying morphine treatments that are standard for babies with neonatal abstinence syndrome — and the children still had the potential for other long-term problems.
But Towers’ research has challenged that standard. Instead of replacement therapy, Towers offered voluntary detoxification programs to help mothers get off of drugs completely before their births. The results have been hundreds of babies born healthy and a much lower rate of children born with acute withdrawal symptoms.
Towers published his findings last fall, and in late July, the American Congress of Obstetricians and Gynecologists [ACOG] — the national physicians group — amended its standards of care to sanction Towers’ detox treatment — with conditions:
“If a woman does not accept treatment with an opioid agonist or treatment is unavailable, medically supervised withdrawal can be considered under the care of a physician experienced in perinatal addiction treatment with informed consent,” according to the revised standard.
Such treatment should include both inpatient care and “intensive outpatient behavioral health follow-up.” Additional follow-up research is also needed, according to the organization.
“We’re chipping away at it. Instead of saying what I’ve been doing is not what ACOG recommends, I now have that option. I’m not a complete outlaw, just a partial outlaw,” Towers said, half-jokingly. “I’m happy with this. People wanted it to be stronger, but I’m OK with it. They’ve opened the door, and I’ll open it further.”
Dr. Bob Elder, an obstetrician and gynecologist at UT Medical Center, welcomes the change.
“For years, [methadone] was the accepted therapy,” he said. “Dr. Towers and I thought that was how it had to be done — that it was unsafe for the mother and the baby to detox them during pregnancy. Now we know that is not the case, and now the American Congress of Obstetrics and Gynecology has given us that as an option for patients who either refuse to do medically assisted therapy or do not have it available.”
Challenging the status quo
When he moved to Knoxville in 2010, Towers was “amazed” at the number of women with an opioid use disorder.
“The first thing they would always say to me is, ‘I did not plan on getting pregnant.’ The second was, ‘I don’t want to be on [any] drugs when I deliver because I don’t want the baby to suffer for my mistakes.’ [That’s] the way they put it,” he said.
Initially, Towers dutifully followed the standard of care and declined their requests but, after repeatedly being asked why not, he began digging.
“I was asked so many times, so I decided to get the two best papers on this topic and put it all together in a little packet so [that] when I see these women and they say they don’t want to do it, I can say, ‘Here, this is why we don’t do [detox].’
“To my surprise, our recommendation is based on two single women in two case reports — two,” Towers said.
The first was published in 1973 involving a woman who was 39 weeks pregnant and taking heroin. The woman couldn’t get the drug, went through withdrawal and had a stillbirth. The second, published in 1975, involved a woman who wanted to come off methadone, but her doctor said that it caused undue stress on the unborn baby and put her back on the drug.
“The second one was Dr. Frederick Zuspan, who I knew. He was a brilliant man and one of the forefathers of maternal fetal medicine. So when Dr. Zuspan said something, for 40 years, it became the standard of care,” Towers said.
The Towers study
Towers uncovered five other studies — published between 1990 and 2013 and apparently all but lost on the medical community — that revealed no problems for babies of women who withdrew from using drugs during pregnancy.
“I wasn’t the first paper. There were five other studies with smaller numbers of participants. They found no problems with the baby by detoxing,” Towers said. “Putting mine together with theirs, we have close to 650 patients [who] detoxed without a loss. The argument that it’s harmful to the baby is false. The addiction medicine world believes that we’re harming babies by doing this, and that’s clearly not the case.”
When opioid addiction and neonatal abstinence syndrome rates began exploding across East Tennessee in 2011, Towers and his colleagues started to actively promote detoxification as an option.
“These women are not coerced. I sit down with my patients, and if they want to detox, I say, ‘I will help you do this,’” Towers said. “It probably takes three to four months on average. But [when] they get off, the vast majority stay off, and they deliver a baby [who] doesn’t have NAS.”
In the study published last year, Towers compared the outcomes of 301 women at different levels of the program. In three of four control groups, 224 women delivered 40 babies with NAS, or about 17.8 percent, compared to a rate of about 80 percent NAS babies for women who remained on opioid therapy.
A group of 93 women underwent “slow outpatient” buprenorphine detoxification; all delivered, and 22 babies were admitted to the neonatal intensive care unit and 16 (17.2 percent) were treated for NAS. Another group of 23 women had inpatient detoxification with “intense behavioral health follow-up.” All of them delivered, but only five babies were admitted to the NICU and four (17.4 percent) had NAS, the study shows.
A group of 108 incarcerated women, who were forced to quit using opioids after being arrested, was also part of the study. All but two delivered, 32 babies were admitted to the NICU with 20 (18.5 percent) treated for NAS.
By contrast, 70 percent — 54 of 77 — of the women who detoxified without the “intensive” behavioral health follow-up delivered babies diagnosed with NAS. In all those cases of NAS, however, every woman either relapsed to drug use or returned to opioid treatment under a doctor’s care.
Each group included women who went through the detoxification program during all three trimesters of pregnancy, including 28 in the first trimester, 148 in the second trimester and 125 in the third.
Towers said even if a woman detoxifies just weeks before giving birth, it improves the baby’s chances of not suffering NAS.
A number of doctors across the country have visited Towers to learn more about his program and consider how to offer it in their own practice.
He is currently engaged in further research that might ultimately spur greater changes.
“If I show that it’s harmful to be on opiates — whether it’s methadone, buprenorphine or heroin, and the baby had NAS — then [the medical community is] promoting a program that causes harm to the newborn,” Towers said. “So maybe the protocol ultimately in pregnancy will be we recommend that, if you’re willing, we detox you, deliver the baby so it doesn’t have NAS and — once you deliver — we put you back on maintenance therapy.”
About 80 percent of the women seen by Towers opt to attempt detoxification before giving birth. But many critics of Towers’ research wonder about the potential for relapse once the mother is out of the program.
“Ever since I presented the main paper and presented the other literature of what’s been done, I’d say most of the high-risk [OB-GYN] docs in the country agree with me. The majority of the high-risk people feel I’m right,” Towers said. “The addiction medicine people are the ones that have a problem with this. If they’re worried about relapse, I get it. If they’re worried about overdosing, I get it.”
The longstanding American Congress of Obstetricians and Gynecologists committee opinion specifically urges physicians to get women with opiate abuse issues into a program of methadone or buprinorphine to minimize those risks. Towers said the key to long-term detoxification success is behavioral health follow-up care.
“The rate of women getting off and going back on opiates is increased if she doesn’t have behavioral health. If I can get a woman off opiates and into behavioral health — and it’s intensive where they’re [regularly] meeting with somebody — the relapse rate is 20 percent, which is way better than the other studies published. If they don’t, the rate of relapse could be as high as 70 percent,” Towers said.
It’s important to note, he added, that women who re-enter a physician-monitored drug replacement program aren’t considered to relapse because they’re under a doctor’s care.
Towers called the majority of his patients “extremely motivated” because of the baby.
“They’re a mom; they don’t want DCS to take their baby away,” he said. “They have someone they’re responsible for, and they realize if they go back on methadone or Subutex [then] they don’t lose the baby. If they go back to street drugs, they could.”
Towers and his Knoxville team are currently doing further research on pregnant women with opioid addictions and the health outcomes of their delivered babies, both with and without NAS.
Struck by the sheer volume of women with opiate issues, Towers has uncovered some troubling commonalities.
“A study will show pregnant women in Appalachia didn’t get into this because they wanted to use opiates as a teenager — like marijuana or alcohol — and got hooked. Or because they had surgery and somebody gave them too many pain pills, and they got hooked that way,” Towers said. “Seventy percent of these women were abused. Sexually abused, physically abused, emotionally abused at the age of 9, 10, 11, 12. The first thing they got into was alcohol or marijuana to hide the psychological pain. I argue they’re treating psychological pain.”
The high rates of NAS in recent years have now injected thousands of children into society who have endured weeks — sometimes months — of specialized care at the beginning of their lives, but studies on their long-term outcomes are still limited.
While there have been some limited studies on NAS outcomes, the high rates of recent years have injected thousands of children into society who endured weeks, and sometimes months, of specialized care at the beginning of their lives.
“Some people say, ‘They have NAS, but they get over it. It’s not a big deal.’ I don’t know if that’s true,” Towers said. “What psychological or brain trauma is occurring to this kid?”
Towers’ ongoing studies on the long-term outcomes will probably be published in 2018, Towers said.
“I think I’m going to show the world [that] staying on opiates and having NAS is not good for the baby,” Towers said. “The addiction medicine people think there may be some damage [to detox babies] we can’t identify that may show up later, but I truly believe they are better off than the ones that have NAS.”
David McGee, Bristol Herald Courier