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Pregnant and Addicted

Overcoming Stigma to Find Treatment

The small waiting room in the basement of Magee Women’s Hospital in Pittsburgh looks more like a business than a doctor’s office. No nurse behind a glass window guards a back area; there’s just a desk in the corner and 11 chairs along the room’s perimeter. Five women and an older man, all accompanied by babies, sit in these chairs.

They chat casually among themselves—about probiotics and trying solid foods for the first time, donating clothes as their babies grow out of them, Halloween costumes. An easy skeleton, or a more complicated lion?

A visibly pregnant woman in sweats turns from examining a display of pamphlets on one wall. “Do you need an interactive recovery workbook for opioid addiction?”

Another woman stops cooing at her six-month-old to laugh. “I think I’m good at this point,” she says. “It’s been a year.”

Two things are equally true about these women: They are mothers (or soon-to-be-mothers), and they are addicts. They come here to the hospital’s Pregnancy Recovery Center (PRC)—one of the first clinics to provide both medication-assisted treatment (MAT) for opioid addiction and prenatal care/delivery—to manage their addiction during pregnancy and after giving birth.

One thing that draws women to the PRC is its willingness to try new strategies. Methadone has long been the gold standard for treating pregnant women addicted to opioids, but the PRC dispenses buprenorphine (brand names Suboxone or Subutex). Buprenorphine is a partial agonist, meaning it blocks some opioid receptors, allowing only a partial response, while methadone is a full agonist, binding completely to receptors, allowing a morphine-like response. Because it’s harder to abuse, buprenorphine is distributed differently. At the PRC, women are first given a weekly prescription and quickly earn a two-week prescription. Methadone requires a patient show up to a clinic every single day to get their dosage. Additionally, most studies find that a smaller number of babies born to mothers on buprenorphine experience withdrawal—neonatal abstinence syndrome (NAS)—than those born to mothers on methadone, and the ones that do require less treatment for a shorter duration.

Methadone and buprenorphine work so differently that while a doctor can get a license to prescribe buprenorphine, only federally regulated clinics can handle methadone. Even so, doctors are still hesitant to prescribe buprenorphine to pregnant women. Most doctors trained in addiction treatment are wary of pregnancy in general, worrying about the effects of medication on the fetus. Obstetricians, by contrast, seldom seek addiction training.

A small group of doctors and administrators at Magee Women’s Hospital decided in 2009 that they wanted to bridge this gap, but it took until 2014 to gather enough support to open the PRC. They saw not only a need for alternatives to methadone (still offered by the hospital), but also an opportunity to save money. Addicts are a high-cost population, explains Michael England, the PRC’s medical director. The PRC is completely outpatient, versus the three-to-five-day inpatient stay required for methadone conversion. It is not necessary to staff a center capable of seeing all patients every day.

The organizing committee knew that for such a project to be a success, it would need a true believer at the helm. Patty Genday, executive director of women’s services, suggested Stephanie Bobby for the job. Genday had been impressed with Bobby, a nurse she’d taught at Indiana University of Pennsylvania. While most nurses and doctors avoided addicts, Bobby sought them out. After her usual hours on the medical surgery unit at Magee, she picked up extra shifts at another hospital’s detox unit. Bobby was the only addiction-certified nurse at Magee.

Stephanie Bobby in her office at the PRC. (Note: The women photographed and/or the hospital gave permission to publish the photos.)

Bobby, both young and youthful, saw a lot of people turn to opioids in the old coal mining town of Northern Cambria, where she grew up, about 90 minutes outside of Pittsburgh. But more than anything, she just likes working with addicts. Bobby likes being able to offer them a new shot at life. She knows how to talk to them—like people, like a friend. She’s made it a practice to first congratulate women, who are often worried about and ashamed of their addiction and pregnancy.

When the committee offered Bobby the job, they only had an idea: a center that offered OB-GYN care, medication-assisted treatment, and behavioral counseling. It’s a three-tiered setup often referred to as the medical home model, because patients get three different aspects of care in one place from providers who coordinate. But that was it. It was entirely up to Bobby how to build and run it.

Bobby had two months. She read all the opioid prescribing guidelines she could get her hands on. She read studies and other literature on the medical home model—often staying up till three in the morning like when she was in college. She ran through mock patient scenarios to see what worked and what didn’t. She consulted the hospital’s legal team to draft language of consent so the different tiers of the clinic could communicate. Bobby discovered that she also needed to provide transportation assistance, legal advocacy, and housing and financial guidance.

When the clinic opened, in July 2014, Bobby did everything besides prescribe medication and deliver babies—scheduling, urine samples, consultations and weekly visits, walking prescriptions to the pharmacy, writing up notes, billing clients, following up and monitoring their progress, answering phone calls and emails, visiting each woman (with gift in hand) after she gave birth.

In January 2017, the PRC received a Center for Excellence grant from the state of Pennsylvania. This allowed Bobby to hire another nurse, an administrative assistant, two peer navigators (who have recovered from opioid addiction), and a designated social worker. She no longer has to do everything herself, but her attitude sets the tone of the clinic. Bobby still brings a gift to each woman after they give birth. She still says “Congratulations!” when she first meets a new patient. Her genuine care for patients is contagious.

The office almost always sounds like the meeting of friends. This is important to Bobby. She doesn’t want to be a recovery mill that fills prescriptions and sends people on their way. She wants to treat patients ethically and spread positivity so the women feel empowered to change their own lives. Pregnancy is a good time to try because something now exists outside the self to worry about.

Bobby gives 24-year-old Ricki a hug and says, “Where’s Zoey?”

Ricki, who is the kind of person you might call bright-eyed and bushy-tailed, explains that her six-week-old is sleeping in a stroller next to her dad, the only man in the waiting room.

“We’ll see her later then,” Bobby says as she leads Ricki into her office, which is full of weird sloth art.

Ricki first used opioids after a miscarriage when she was 18. The pill her boyfriend gave her made her feel sick, and she told him she wouldn’t do it again. But as it settled in, she realized that it erased her emotions—not just regarding the loss of the baby, but everything. The rape at 15, the arguments with her parents. Everything. Feeling sick suddenly felt worth it.

Ricki soon graduated to heroin because it was much cheaper. In January, after she found out she was pregnant, Ricki continued to use, telling herself she’d probably just have another miscarriage.

One day in late May, Ricki went to see her dealer. She shot up at the top of a flight of stairs, like she always did, before walking back to her car. As she rounded the corner, Ricki spotted three bullet holes in the side of her car. At the exact same moment, she felt the baby kick for the first time.

The exact same moment.

Something awakened in Ricki’s heart. Addiction was no longer about just her life. She drove directly to the hospital and asked for help.

The hospital suggested methadone conversion. But Ricki had seen friends and boyfriends on methadone and didn’t want a life that revolved around getting what she needed in her system. She hoped for a way to break that addict mentality. She was told about the PRC and sent to Bobby. Elizabeth Krans, an obstetrician at the PRC, says the center is making sure all hospital staff know to present both options—traditional addiction aid and the PRC—for a “shared decision-making process.”

Ricki, around 22 weeks pregnant, on the day she found out she was having a girl.

Most studies find that a meaningfully smaller number of babies born to moms on buprenorphine have NAS than those born to mothers on methadone. But the only double-blind study done to date, the MOTHER study, led by Hendrée Jones, did not corroborate the difference. This is shocking considering that many other studies find the difference is as much as 37 percent for buprenorphine to 75 percent for methadone. Jones chalks up this drastic contradiction to stigma—in this case, on the part of the doctors prescribing the meds. Methadone is fundamentally seen as a heavier medication, more of a “drug” than buprenorphine. The idea is this affects the way nurses and researchers judge a baby’s response, because NAS is based on subjective human judgement—how much the baby cries and how often, etc.

Importantly, the MOTHER study, like other studies, did find that buprenorphine results in less-severe NAS—it requires less morphine to treat it and for a shorter period of time. While it still seems the better option, Jones says the drug used really depends on the person. Methadone can be used to treat multiple drugs, while buprenorphine requires that a patient has whittled usage down to opioids only.

Buprenorphine isn’t without stigma. Ricki doesn’t have to worry about this—now that she’s taking care of her baby and not using, her family is completely supportive. She lives with them, and her mom or dad drives the two hours to Pittsburgh with her every week for her appointment. But that isn’t the case for everyone.

Megan, the peer navigator who went through the PRC (her name has been changed to protect her identity), had a baby who experienced withdrawal. All PRC babies stay in the hospital for five to seven days because withdrawal doesn’t always immediately present itself. Megan’s child needed to stay for 17 days. She was worried about what people would think—nobody besides her husband, also an addict, knew she was on buprenorphine—so Megan had to keep coming up with excuses, like jaundice, to explain why her baby was still in the hospital. But it’s not just the outside world. Megan was treated poorly by some nurses—“like a junkie.” She felt bad enough that she did this to her baby. “But I could not stop using, so it had to be this way.”

Ricki with her mom, Pam, and Zoey.

Jones says there are no documented long-term effects of either drug. She has done follow-up with the babies born as part of the MOTHER study 36 months later, and they were within the normal range of development—on the low end, but normal. There are things that we know affect babies—alcohol, cigarettes, environment—and it’s hard to separate those factors from each other.

This is exactly the kind of stigma that Bobby and the others are battling. Now that Megan is a peer navigator, she tells “her girls” this story. She tells them “if anyone treats you like a junkie,” call patient relations.

After Ricki finishes with Bobby, she goes into Krans’ office. (Krans delivered Ricki’s baby.) Her dad and Zoey come, too. The sign on the desk reads, “Every day I’m hustling.” They discuss switching Ricki from Subutex tabs (pure buprenorphine) to Suboxone films (buprenorphine paired with naloxone, which makes overdose impossible) now that she’s given birth. Until May of this year, the PRC was transferring women to another clinic six weeks postpartum, but relapses frequently occurred. A woman had just given birth, and suddenly all her support changed. As Krans says, the medication is only a small part of the treatment. People get attached.

Ricki and both her parents attribute her success to the clinic. “It saved her life,” her parents say. “We got our daughter back. We’d be picking out a casket instead of a crib.”

Since the PRC began allowing women to stay indefinitely, 85 percent remain in their care. It’s a small sample—about 30 patients—but the results show promise, Bobby says. “We’re looking for other ways to fill gaps in care, too.” Rural communities, for example, often have large addict populations but lack the infrastructure to treat it. The PRC currently has five rural centers linked through telemedicine, a traveling social worker, and local services.

Stephanie Bobby with Ricki and Zoey.

As for Ricki, she knows she wants to get off the buprenorphine, but Krans doesn’t think she’s ready. Ricki puts her trust in the PRC entirely. Some patients can get off the medication when they have everything else in place. But abstinence is not always the goal. Bobby compares it to diabetes—diet and exercise help, “but we don’t cut off their supply of insulin at some point.”

If the opioid epidemic does one thing, says Krans, she wants it to be “bringing this particular medical disorder into the fold so medical professionals know how to treat it when they see it.” The PRC’s model has a high rate of success, at 59 percent overall. Women are getting and staying clean—they’re capable of holding jobs, raising their children, participating in friendships and family relationships. But is the answer really always the same? What about women who do better on methadone? Does being “clean” require abstinence? How do they find treatment that works for them? Most people agree that there are no absolutes, but it’s people like Bobby, with her alternative approach and genuine interest in women most people would rather not think about, who increase the range of options for recovery.