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Special Delivery

Niche clinics address high-risk pregnancies

Although a normal pregnancy and delivery of a healthy child are every woman’s goal, sometimes challenges arise that require specialized care for both the mother and baby. For four decades, Vanderbilt has provided innovative specialty clinics to assist high-risk pregnant women and will continue to target specific health needs for this population.

One of these clinics was the difference between life and death for Claire Moseley and her unborn child.

Six months pregnant and addicted to opioids, Moseley, 26, was running out of options. She was discovering there were three outcomes for addicts other than recovery: jail, rehabilitation centers or death.

“I had already been to jail,” said Moseley. “I had been to rehab, twice. There was only one thing left and that was death.”

The young mother, challenged by feelings of guilt, shame and regret, calls her son a miracle. Born three weeks early on Nov. 18, 2012, Vann weighed 5 pounds and 13 ounces.

Surrounded by family and friends, she recently hosted a birthday party, which was more than a celebration of her son’s first year. It was also recognition of her accomplishment—sobriety.

Moseley credits Jessica Young, M.D., assistant professor of Obstetrics and Gynecology, for her success. Young runs Vanderbilt’s Drug Dependency Clinic for pregnant women, one of a few of its kind in the country.

“I have no doubt that if I had not gotten help I would have overdosed at some point and I am certain that my son would have either not made it or would have been born with a lot of health problems,” Moseley said. “He has been perfectly healthy from day one and never shown any negative signs of my drug use.

“At first, no part of me felt that I deserved this sweet, healthy baby. But when he was born—there was nothing in this world more important to me than staying sober so that I could be a good mom.

“He deserves 100 percent of me and if I am not sober, I cannot give that to him.”

 

Leading the Way

“Vanderbilt has taken a leadership role in opening these clinics that cater to a specific patient population. Other medical centers will follow in creating similar clinics for pregnant women with specialty needs,” said Frank Boehm, M.D., professor and vice chair of OB-GYN.

For example, Vanderbilt Psychiatric Hospital was the first in the region to use buprenorphine when it opened a clinic in 2005 to treat dependency to opioids including heroin and other widely prescribed pain control medications like oxycontin, lortab, and percocet that are highly addictive.
Buprenorphine carries a lower risk of abuse, addiction and side effects, and most importantly, blocks the craving for other opioids. It is one of three medications commonly used to treat opioid addiction.

According to medical reports, buprenorphine makes the brain think it is receiving an opioid, which keeps withdrawal symptoms at bay. While taking the medication, the patient feels normal, not high.

“The golden standard for opioid addiction during pregnancy is methadone and I wanted to steer clear of it,” said Moseley. “I wanted to have the least amount of side effects for my baby. I had seen grown men detoxing from methadone and it was horrible. I just couldn’t do that to my baby.

“Without this clinic, I don’t think I would have been able to stay clean. It is so hard to overcome, but Dr. Young really worked with me—finding the right doses of medication that worked for me and not fitting me into a category.

“Everyone in the clinic was rooting for me, working with me so that I could be successful. Never once did I feel judged.”

That was music to Young’s ears. She has worked to ensure that her clinic is a safe and nonjudgmental environment for mothers seeking health care and drug treatment.

Many patients are burdened with fear, worry and guilt, all of which serve as barriers to care, she pointed out. Young and her staff work to peel away those layers in hopes of helping women make a lifestyle change.

“Our challenge is to help them not only overcome those fears but to also build a therapeutic relationship of trust—I must trust them and they must trust me. In order to do that, I have to meet them with respect and listen to their stories.

“The overarching goal is to get them and their baby through their pregnancy in the healthiest way possible,” she said. “Secondary is getting them to a place in their recovery where they will remain stable after delivery, after the postpartum period and beyond.”

Patients like Moseley inspire and motivate Young to continue her efforts to help this patient population.

“I feel lucky to just play a small part in helping them, but they are really the ones doing all the work,” said Young. “They are the ones finding the power within to make the change. I am just giving them the tools; they must decide to use them or not.”

For Moseley, who had been fighting an opioid addiction on and off for nearly five years, the clinic was her saving grace. What started as recreational use of an acquaintance’s leftover dose, turned into a hard-hitting heroin habit.

“When I first started, I took small amounts of oxycontin here and there,” recalled Moseley. “At the time, it was easy to get. I had no idea that I had become addicted until I couldn’t get it anymore and I got sick.

“It didn’t seem dangerous or a big deal. It really took me off guard that I was addicted. I switched to heroin because it was easier to find, lots cheaper and the high lasted longer.”

Moseley was nearly through the first trimester when she learned she was pregnant. She was admitted to her second rehab facility, an out-of-state center that accepted pregnant women.

Three months later she returned home, detoxed and ready to move forward, until an injury from a bathtub fall a few weeks later sparked her urge to use drugs. Although not as intense as before, she had relapsed.

“I wanted so badly to stay clean, but it seemed like any kind of pain or stress … I had a really strong addiction. I was admitted to Vanderbilt to begin buprenorphine so that they could monitor both me and the baby.”

 

Relying on research

Vanderbilt was one of eight sites to test the use of buprenorphine in expectant mothers in a trial which was part of the MOTHER project—Maternal Opioid Treatment: Human Experimental Research.

The results of the study were documented in a 2010 issue of the New England Journal of Medicine. The study, co-authored by Vanderbilt’s Peter Martin, M.D., director of the Division of Addiction Psychiatry, found that the newer buprenorphine is at least as good for both mother and child as methadone, the standard of care, when both were combined with comprehensive treatment of opioid dependence in pregnant women.

“We demonstrated a statistically significant improvement above the standard of care in important outcomes in the babies of mothers who received buprenorphine during the pregnancy compared to those who were administered methadone,” Martin said.

Buprenorphine had previously not been well studied in pregnancy, although it is now widely prescribed to treat opioid addiction.

Study results showed that babies of mothers who received buprenorphine compared to those who received methadone throughout pregnancy needed significantly less morphine to treat their neonatal abstinence syndrome (NAS), had shorter hospital stays (10 days vs. 17.5 days), and shorter duration of treatment for NAS (4.1 days vs. 9.9. days).

It was soon after that study was published that Young and her colleagues began to notice an increase in the number of expectant mothers who were opioid dependent. There was also a spike in NAS births in Tennessee.

Vanderbilt clinicians took action. Since opening in the fall of 2011, the
clinic has treated about 150 patients.

Originally a once-a-week, half-day clinic, the Drug Dependency Clinic now operates twice a week to meet the increasing patient volume. The clinic follows 30-50 women. The appointment schedule is completely booked.

Young is not sure what to make of the growing population.

“We are at the point where it’s hard to tell if we are offering a service that people need, and utilization is up, or whether the number of women addicted to these medicines is increasing,” she said. “I worry that it is the latter.”

Young said one-third of her patients’ drug abuse begins with an injury or pain after a surgical procedure. Another third have been treated in pain clinics, while one-third are patients whose recreational drug use escalated, like Moseley.

Ultimately Young hopes to expand the clinic in order to meet the growing demands. There is currently a collaborative model with patient care including obstetrics, psychiatry and social work. They would like to expand to include case management and group therapy.

“There have been studies that show that integrating prenatal care with addiction treatment improves outcomes,” said Young. “We are trying to get a handle on the epidemic and figure out the best way to treat these women. I want to bring everything into one place to make it easier for them. We want to give them every opportunity to be successful.”

 

A team approach

One of the clinicians treating Moseley, Michael Caucci, M.D., assistant professor of Clinical Psychiatry and OB-GYN, runs the Vanderbilt University Women’s Mental Health Clinic at Vanderbilt Health One Hundred Oaks.

Caucci and Young team up prior to a patient’s delivery and immediately after the baby is born. He typically follows patients for three months postpartum to make sure they are stabilized.

This concept is not only beneficial for the patients, but also creates a collaborative environment for our clinicians, Boehm said. “That team approach allows them to provide care in an all-encompassing manner.”

Moseley sees Caucci every month to monitor her buprenorphine dose. The pair will work together to create an appropriate tapering schedule.

Caucci is pleased with Moseley’s progress.

“She has worked really hard in her recovery to achieve this success,” said Caucci. “I am glad that we are able to offer services to women to enable them to get through their pregnancies safely, educate them about their addiction and the effects it has on their baby as well as continue therapy to get them on the road to recovery.

“We want to end the drug abuse, but first, we have to get at what is causing it. It goes beyond the delivery. This impacts the rest of their lives and their child.”