BEMIDJI, Minn. – Few things have been as heart-wrenching for obstetrics doctors and nurses at Sanford Bemidji Medical Center in recent years as helpless newborns hooked on the opioid drugs their mothers abused during or before pregnancy.
Many of the infants recoil at a nurse's touch, cry constantly, clench their muscles tightly, and tremble and sweat profusely.
"A diaper change can totally put these kids on the edge," said Lisa Johnson, nurse manager of the hospital's critical care nursery.
The tragedy has grown in lockstep with Minnesota's rising number of overdoses and deaths from prescription opioid painkillers or illicit versions such as heroin — particularly in rural counties near American Indian reservations, where the opioid epidemic has been harshest. The number of babies born at Sanford Bemidji and placed on 72-hour protective holds due to positive drug tests has tripled since 2008, from 25 to 75 last year.
But now, for the first time, a concentrated effort at Sanford Bemidji to support addicted mothers before their deliveries has started to make a difference. And hospital leaders across Minnesota are hoping to expand on the success of Sanford Bemidji's First Steps to Healthy Babies program to combat a worsening opioid epidemic.
"What should be a joyous occasion of a new mom coddling, nurturing and feeding her new baby turns into a horrific situation," said Dr. Rahul Koranne, chief medical officer of the Minnesota Hospital Association. "Our viewpoint is that every mom should be assessed for this. That's the only way we're going to get at diagnosing addiction and getting help before the baby is born."
At Sanford Bemidji, the solution has gone beyond identification and treatment, though they are critical components. Sanford's medication-assisted therapy clinic in Bemidji prescribes buprenorphine to eliminate opioid cravings for women while they are pregnant, which also reduces the chances of premature births.
The treatment itself leaves newborns prone to withdrawal symptoms after birth, so it is somewhat controversial, but mothers often cannot overcome opioid addiction without it, said Dr. Joe Corser, who directs the clinic. And if there is any hint that the mothers are still abusing drugs, their newborns often have to be placed in foster care.
Using buprenorphine for "the safety of mom so she can nurse the baby, bond with the baby, go home with the baby is so beneficial," he said.
Using a $1.7 million grant from PrimeWest Health, Sanford hospital leaders teamed up with child welfare and social service specialists in Beltrami County and the Red Lake Reservation. Crucially, they not only screen for opioid addiction and treat it in expectant mothers, but also identify underlying problems such as a lack of stable housing or mental health care that helped fuel those addictions.
Research at the University of Minnesota shows that women often have depression, anxiety and other problems that coincide with opioid use, which in turn results in poor decisionmaking and an increased rate of unplanned pregnancies.
"If you leave the depression and anxiety untreated while you work on the opioid use disorder, you're leaving someone with a vulnerability that might bring them back" to drug abuse after childbirth, said Katy Kozhimannil, a U public health researcher.
On the other hand, her analysis of survey results found that 5 percent of pregnant women in the U.S. admitted to opioid use in the prior year, but only 1 percent used opioids in the prior month — suggesting that many are motivated to quit because of their pregnancies.
Ashley Benson figures she'd be dead were it not for the birth of her fourth child, Grayson, last year. The pregnancy compelled her to stick with medication therapy for her opioid addiction and to leave an abusive home in Mahnomen on the White Earth Reservation, and come to Bemidji with almost nothing but her kids. She said the First Steps program was critical in keeping her in treatment and finding affordable housing, transportation and child care.
"Grayson definitely saved my life," she said.
Benson, 29, said her addiction started with prescription opioids she received as a teenager for a basketball injury to her knee, and then for a punctured lung she suffered in a car accident months later. Combined with the prevalence of illicit drugs at White Earth and the abuse she suffered, Benson said it was easy to succumb to drug use.
"I was taking the meds to numb myself," she said.
Initially, the First Steps program was viewed with suspicion, especially at Red Lake, where mothers suspected it was a ruse to get them to admit their addictions so their babies could be taken away, said Jean Donnell, a family and children services case manager at Red Lake. "We had to work through that."
But leaders hope the program's incentives — sometimes as small as a gas card so women can make medical appointments or drug screens — will help, along with success stories such as Benson's.
In 2015, 74 babies were born at Sanford Bemidji with neonatal abstinence syndrome, or NAS, which is the clinical term for withdrawal symptoms caused by prenatal opioid exposure. Of those, 60 percent were placed in foster care, mostly those whose mothers weren't taking opioid medication therapy and were suspected of still abusing drugs.
In the first half of 2016, only 54 percent of babies born with NAS ended up in foster care, mostly because First Steps got a higher rate of mothers screened and into medication-assisted treatment.
Grant funding for the program lasts only through 2017, but First Steps leaders said they are confident the hospital and social service agencies will continue to support it. A culture of blaming moms for getting addicted and hurting their babies has started to change as more people in the community understand the insidious nature of opioids, Johnson said.
Volunteers to rock and comfort NAS newborns are so plentiful that the hospital now has a waiting list.
Statewide, the rate of state-funded deliveries resulting in babies with NAS spiked from 5.1 deliveries per 1,000 in 2010 to 14 per 1,000 in 2015. However, that rate dropped to 12.9 last year.
"They are at least not getting worse," said Dr. Jeff Schiff, medical director of Minnesota's Medicaid program, who credits community treatment programs, including First Steps and a similar MOMS program on the White Earth reservation.
State hospital officials have created a tool kit based on these successes so other hospitals can adopt the approach.
Research is unclear on the long-term medical consequences for infants of NAS and medication treatment. Some studies have compared different forms of medication therapy — from the buprenorphine that Sanford prescribes to the methadone that is potentially more addictive and acts in the body more like opioids — but find no long-term developmental problems in children exposed to one over the other.
Watching babies suffer withdrawal symptoms can be traumatic for new mothers. Some blame the medication even while they blame themselves. After birth, the babies' withdrawal symptoms are rated, and if they get bad enough, they receive the opioid morphine that is gradually reduced to help them cope.
Benson said that was hard, watching her newborn squirm and struggle to find comfort and knowing it ultimately came from the medication she was taking to stay sober.
"That guilt, all the emotions and everything that rolls with that," she said, "it was awful."
Her baby's symptoms gradually diminished over time, though. Benson took him home, where she said the problem now is that the 4-month-old is growing so strong so fast that he is able to roll around and elude his mother's watchful eye.