by Cynthia Daubman, RN, MS and Kathleen Anderson, RN, CASAC

Handcuffs and an orange jumpsuit were her debut ensemble. She was escorted to her first visit to the methadone clinic by several stern, uniformed corrections officers. Their ominous presence caused quite a stir among the other patients, making some uncomfortable, evoking unwelcome memories and triggering flashbacks. This new patient would have to work extra hard to overcome such a negative first impression. Inmates of the county jail are never brought to our clinic, yet here she was. The intake process, which usually lasts several weeks, was shortened to two hours for her. The reason? She was pregnant. Four months pregnant.

A pre-birth baby of a drug addict experiences the same highs and withdrawals as the mother, who would complain of vomiting, dairrhea, slight fever, yawning, body aches, insomnia, runny eyes and nose, sweating, chills and goose flesh (‘cold turkey’). Another symptom of withdrawal which could be very significant is muscle twitches, also called ‘kicking’, hence the term ‘kicking the habit’. In this case, muscle twitches could take the menacing form of uterine contractions, causing miscarriage. For this woman, withdrawal could mean more than drug hunger, more than the tortures of immediate heroin abstinence – it could mean the death of her child. The intrauterine milieu must be kept in a steady state. Methadone can do that.

A methadone clinic counselor interviewed the woman, whose head and arms stuck out of cavernous holes in the too-big jumpsuit. Her short, dyed-black hair was matted and unwashed, betraying depression. She sat with sagging shoulders and responded to rote questions with a monotone voice and apathetic manner as the counselor filled in page after page of the intake form. Each response gave more detail to the story of her drug and alcohol addiction: the journey traveled from the dysfunctional family of origin, through a sordid adolescence, proceeding to chemical abuse and addiction, and ending in jail. Financial, criminal and employment information were elicited. These vital statistics comprise the individual tiles forming the mosaic of her life.

Then the clinic medical director, a psychiatrist, did a physical exam and a psychiatric evaluation. He perceived her general wasted appearance. He perceived her general wasted appearance and found tracks on her arms. She was symptomatic of malnutrition: lusterless eyes set in dark hollows of a sallow, gaunt face, poor muscle tone, and corroded teeth in inflamed gums. Clinical depression was manifested by lack of self-esteem and ego-strength, and feelings of guilt, shame, and despair. A very carefully considered, conservative first dose of methadone was prescribed, with small, incremental increases to be judiciously administered by the clinic nurses in the days to come. It is the philosophy of this clinic that the dosage amount should be patient-driven: increases would continue almost daily until the patient reported no more withdrawal. At that point the maintenance dose would be considered reached, with methadone filling approximately 75% of the opiate receptors in her brain, creating peace for the mother’s mind and body and homeostasis for her baby.

A clinic nurse obtained specimens for bloodwork, urinalysis and toxicology for illicit drugs, the results of which would later be reviewed with the patient by the doctor. The patient was then escorted to the dosing window, where her prescribed dose was dissolved in water, as per New York state regulations, so that the pills cannot be pocketed in the cheek, diverted to be sold later. There at the window the patient received a smile, along with some friendly, encouraging words, and so experienced the care and compassion that are meted out with the bitter, bright orange liquid which matched her jail garb.

The benefits of methadone maintenance far outweigh the risks for the fetus. Withdrawal could cause the fetus to experience discomfort, death and spontaneous abortion. The mother’s use of illicit street drugs, in an effort to avert withdrawal, could result in alternating periods of extreme highs and dangerous lows, presenting severe physical challenges to the baby’s survival. Ingredients of street drugs vary; drugs are cut with various adulterants such as baby laxative, milk powder, cocoa and face powder to increase bulk, making shooting up a game of Russian roulette. The chemically controlled consistency of legitimately manufactured methadone is relatively benign in comparison to the variable chemical cocktail of illicit drugs. At the clinic, the prescribed amount of methadone can be split into morning and evening doses, in an even more conscientious effort to maintain an intrauterine steady state.

Could methadone harm the developing baby? Methadone may cross the placental barrier. Some infants born to mothers dependent on methadone have had various defects, but it is uncertain if any were caused by methadone, as addicted mothers and their fetuses, prior to methadone maintenance, often experience malnutrition, disease, lack of prenatal care, and the dangerous vagaries of street drug ingredients. Methadone can reach the baby’s opiate receptors, chemical islands floating on the cerebral membranes, thereby creating the possibility of the baby’s being born addicted to methadone. Hospital personnel, alerted to the mother’s use of methadone by the patient and/or clinic staff, monitor newborns for signs of infant withdrawal using such tools as the Brazelton Neonatal Assessment Scale. Some babies show no signs of withdrawal. If needed, the infant’s detox can be managed with decreasing amounts of narcotics while it is still in the hospital. Breastfeeding is often recommended to mothers who are not positive for HIV or hepatitis, as nursing the baby promotes bonding of mother and baby, comforts a detoxing baby, and provides small amounts of methadone in the breastmilk.

The ideal situation for any baby would be no drugs and no methadone, but the real situation for this baby is the monster of addiction, a potential killer. No jail wants that lawsuit. No moral person wants to be responsible for death, so the staff of both jail and clinic synchronize and mobilize. Here, there is a legitimate place for methadone treatment for health, for recovery, for literal survival.

The baby was born five months later, a serene, tiny angel, the perfect embodiment of all our good intentions and efforts. The mother had been released from jail two weeks after beginning dosing at the clinic, and gave birth as a free woman, dependant on methadone. Having overcome her first impressions at the clinic, she is now a resource person to other pregnant patients and new mothers. In fact, she has been a positive influence on her own mother, who has also become our patient. They both attend the clinic faithfully. The baby clings to them, watching with wide-eyed alertness her two lively older brothers, ages four and five. She is a blessing baby, a joy to the entire staff, our diminutive princess, a constant reminder of the full picture of recovery. She is the product of our caring: a visible, huggable reason to do what we do. Sometimes our goals
are mere words written on a patient’s treatment plan – intangible and often difficult to quantify or verify. This baby is a positive outcome we can hold in our arms, a gift of hope.

She is Recovery.

She is a recovering addict, and methadone assisted in the miracle of her life.

Note: Pregnancy is a frequent by-product of drug and alcohol use, which lessen inhibitions and impair judgment. Sometimes patients lose their babies for various reasons, and sometimes they choose to abort. But every methadone clinic has many babies born to mothers receiving methadone. Each baby is a miracle to the staff – a ‘raison d’être’.

The woman in this article is a composite of many patients and does not identify one particular person.

Cynthia Daubman, RN, MS and Kathleen Anderson, RN, CASAC work at a methadone clinic serving 240 patients, mostly heroin addicts, though some come with run-away addictions to painkillers. Cynthia is a member of NAMA, National Association of Methadone Advocates. Kathleen is a CASAC who serves as a liason between methadone staff and a cooperating agency providing more intensive out-patient counseling to some clinic patients. Cynthia can be reached at cynthiad@dcdmh.org.