Now and then, an attorney will ask me to provide an expert opinion on addiction. I can usually quickly review records to find issues that attorneys might miss.   Moreover, with access to electronic libraries, it usually does not take long to find articles supporting my opinion. I come from a family of attorneys, and I see it as my civic duty to help the legal profession get things right.   Ideally. I recently found myself in a case involving methadone, a dead baby, and a rushed judge.

I will not wholly identify my most recent case for the sake of privacy for those involved. Anyone who needs more information can find it without too much trouble. The case was heard in Federal Court in Wisconsin. Area news media reported on the case in 2017 but appears to have lost interest. Reporters covering the case in 2017 did not respond to my emails.

The parole officer of a woman at 34 weeks gestation had the woman jailed after finding cocaine metabolites in her urine. The woman was on methadone, 150 mg/day, as part of her treatment for opioid use disorder.   She was held in a Milwaukee jail that neglected to continue her methadone, and after about 3-4 days, she stopped feeling fetal movement. Jail health staff spent several hours searching for heart tones with an ultrasound device before sending her to the hospital, where doctors delivered a dead fetus. 

People have differing opinions on abortion, but a 34-week fetus is a baby.   If the mother had delivered her baby at  34 weeks, both mother and baby would probably be home together now, and the baby would now be seven years old.

The main question now was whether the jail bore any responsibility for the baby’s death. As with any case, both sides had experts. I planned to start my testimony by teaching the jury a few basics, including tolerance, methadone-assisted treatment, the physiology of opioid withdrawal, and the nature of endorphin systems that methadone replaces. Then I would explain why sudden discontinuation of methadone leads to profound changes in any human body – changes in metabolism, blood flow, and neuromuscular function that severely stress a fetus or infant.

It did not work out that way. The judge was determined to push the case along very quickly. He ordered me to stick only to this case whenever I tried to describe the science. My testimony lasted barely an hour, and the case concluded after 2 ½ days and an hour with the jury.  

Could you decide a case like this without knowing something about the consequences of suddenly stopping methadone?

I felt horrible after the verdict because I did not believe justice was done.   The case lasted seven years, only to be decided in two days by an uneducated jury.    

Yet there is more to the story.

During a deposition for the case a few years ago, I was questioned about the ‘Bell paper.’ In 2016, Jennifer Bell et al. released a study of about 400 pregnant women who discontinued methadone during their pregnancy.   The lawyer tied that study to the experience of the mother and claimed the study showed that opioid detox during pregnancy was not harmful. The Bell study had several groups. About 100 subjects were detoxed suddenly in jail. Two fetal deaths occurred in that group. One group of women were detoxed over weeks or months using comfort medications and buprenorphine. Some women were detoxed in the hospital over 6- 8 days. In other words, most subjects of the Bell study were tapered off opioids, not suddenly detoxed while unmonitored in jails.

Reducing opioids during pregnancy has been considered dangerous and against the standard of care since the 1970s, when studies showed risk of miscarriage or fetal death. There have been other studies over the years that made similar conclusions.   Methadone programs are not allowed to make dose reductions during pregnancy. When I worked in that industry, women wanting to taper were tested for pregnancy and not allowed to reduce their dose if pregnant.

Tennessee has been an outlier in the field of addiction treatment.   It was the only state to outlaw plain buprenorphine, a silly move with no basis in science. Women who delivered a baby dependent on opioids, until recently, could be charged for a form of child abuse. 

Researchers in Tennessee produced the 2016 Bell paper. They admitted in the introduction that the study was motivated by the high cost of care for babies born with NAS, or neonatal abstinence syndrome. NAS babies are often challenging to soothe, have spastic limb movements, have trouble feeding, and exhibit other symptoms that require care in neonatal ICU’s for weeks or months.  

The reason for their symptoms (that I was not able to explain in court) is that use of any opioid causes tolerance, where activity downstream from opioid receptors becomes ‘downregulated’. The brain’s endorphins and enkephalins lose function as they are not potent enough to activate tolerant opioid pathways. Endorphins are ubiquitous in the human body,  acting in the brainstem, cortex, spinal cord, hypothalamus, GI tract, and immune cells in the bloodstream. Sudden withdrawal of opioid tone causes surges of adrenaline that impact cardiovascular function. Adults describe opioid withdrawal as a horrible process, usually associated with significant weight loss and depression.

I do not mean to be critical of the study’s authors because I do not know them, and they must work according to the laws of their state. But at least some attorneys saw the study as proof that women can discontinue opioids when their fetus lives inside the uterus, its jerking limbs and high-pitched cries hidden from view.

Misguided attorneys are one thing. However, the Bell  paper appears to have set off discussions within the OB community. Those poor NAS babies in the NICU are heart-wrenching. What if we could do that work BEFORE delivery?

Other authors have pointed out that using ‘death’ as an outcome measure is not what US healthcare strives to accomplish. Opioid withdrawal places great stress on the fetal brain, causing changes that impact adulthood. Beyond that, subjects in the 2016 Bell study had high relapse rates after stopping methadone or buprenorphine.

I don’t know how many states are looking to reduce budgets by pushing NAS into the womb, but I hope we don’t move in that direction.  If we force the withdrawal from sudden detox upon the most innocent and fragile members of society, the least we should do is keep our eyes open and help them through it.   

Bell J, Towers CV, Hennessy MD, et al. Detoxification from opiate drugs during pregnancy. Am J Obstet Gynecol 2016 Mar 17.

 McCarthy et al. Opioid dependence and pregnancy: minimizing stress on the fetal brain.  Am J Obstet Gynecol 2017 Mar;216(3):226-231.


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