Newborn addicitions

Dr. Mary Guinan, one of the nation’s most distinguished physicians, is calling on the Nevada Legislature to look at long-acting reversible contraceptives (LARC) to deal with one of the consequences of opioid addiction.

“An addictive baby is born every 15 minutes,” she said. “The states have to take control of this.”

An infant born going through withdrawal is called neonatal abstinence syndrome (NAS).

The types of birth control she references include injections, intrauterine devices and implants inserted under the skin, methods that function at all times and do not require action at the time of intercourse. This would prevent virtually all pregnancies during the years-long period the devices are functional. Failure rates are extremely low, certainly compared to the pill and other methods.

The Centers for Disease Control would normally be expected to lead on this matter, but that has not happened.

Guinan, a founder of the School of Community Health Sciences in Las Vegas and a member of the original Centers for Disease Control team in the 1980s that did pioneering work on AIDS, said the CDC is prevented not by law or rule but informally by politics from dealing with birth control matters as a preventive in the opioid epidemic. Like many public agencies, the CDC is often in the uncomfortable position of being pressured to cool its messages.

There can be reluctance in the agency to deal with birth control issues because, under some presidential administrations and Republican majorities in Congress, when sensitive political issues arise, the agency can be targeted for retribution, sometimes through its budget. And Guinan suspects that has been reflected by the unwillingness of the CDC to lead on the infant addiction issue.

“There is nothing coming from the CDC on this,” Guinan said. In addition, she said, “There is no protocol for treating [the infants].”

Nor is it just CDC, she said—few public health agencies have stepped up.

A 2015 study in Clinical Obstetrics and Gynecology said:

“OD [opioid dependent] women are at significant risk for unplanned pregnancy, and postpartum contraception intention should be discussed throughout the prenatal care period. In an evaluation of 946 OD pregnant women, 89 percent of pregnancies were unintended compared to 31-47 percent of the general population. Long acting reversible contraception (LARC) such as intrauterine devices (IUDs) and subdermal implants should be encouraged over other methods due to significantly greater continuation rates when used for postpartum contraception. To further reduce the risk of unplanned pregnancy, immediate post-placental IUD placement or insertion of subdermal implants prior to patient discharge after delivery should also be considered to reduce barriers to LARC use such as poor compliance with the postpartum visit.”

The March of Dimes has issued warnings like, “If you’re not pregnant and you’re using opioids, use birth control until you’re ready to get pregnant. This can help prevent NAS in your baby.” But how widely such warnings are heard and seen is unknown.

The problem is particularly acute in rural areas. Last year, the Journal of the American Medical Association published a study that confirmed previous studies suggesting opioid abuse was “increasing rapidly in some rural states”—about 600 percent from 2004 to 2013. Nevada’s rural areas make up about six percent of the state’s population. The same study also said, “Compared with their urban peers, rural infants and mothers with opioid-related diagnoses were more likely to be from lower-income families, have public insurance, and be transferred to another hospital following delivery. The proportion of infants diagnosed with NAS who were from rural counties increased from 12.9 percent in 2003/2004 to 21.2 percent in 2012/2013.”

That is in contrast with the situation in the urban areas, where opioid abuse is thought of as more upscale than some other addictions, and as afflicting whites more than some other drugs do.

Seven dirty words

Guinan said she has discussed the matter with state Health and Human Services Director Richard Whitley, and that they have discussed the possibility of legislation. There is no certainty regarding what form legislation would take. Whitely was not immediately available for comment. But a considered policy would be preferable to leaving the consequences to chance.

In Kentucky, for instance, where no state policy exists, one judge fashioned his own, offering opioid defendants the chance to knock two days off their sentences if they attend a NAS educational program provided by the state. addition, he offered 30 days off to defendants who undergo a vasectomy or a contraception implant—a remedy, if such it is, that has prompted debate and controversy.

In a pilot program in northeast Tennessee, female drug inmates were offered LARC.

That kind of ad-hoc policymaking would be avoided with legislative consideration of the problem and adoption of a state policy. But Nevada’s very short legislative sessions do not lend themselves to thoughtful policy-making.

The participation of the CDC, with its credibility and the responsiveness of journalists to its work would make it an important player in the addicted baby matter.

“I had to avoid the topic when I was there,” she said. She was employed at the CDC for 20 years, 1978-1998, and held titles like associate director for science.

The word sensitivity at the agency tends to ebb and flow, depending on the presidential administration in power, one source told us.

In December 2017, leaked documents indicated that employees at the CDC were advised to avoid seven terms. The words did not include contraception or related terms, but the dispute did make known a sensitivity to words that could cause public relations problems. The seven words are vulnerable, diversity, entitlement, transgender, fetus, evidence-based and science-based. And Guinan says the sensitivity to birth control long pre-dated the seven words during the Trump administration.