Every 25 minutes
Every 25 minutes, a baby is born addicted to opiates and will soon suffer from opioid withdrawal (Dramatic). Not only is this opioid epidemic happening and affecting families around the United States, but it is also causing a major problem in the Cherokee Nation, a Native American community in Tahlequah, Oklahoma. Native Americans have one of the highest substance abuse rate, as well as, drug-induced deaths in the country (Locker). The Cherokee Nation is made up of 14 different counties surrounding Tahlequah. Cherokee, Adair, Sequoyah, Nowata, Muskogee, Wagner, McIntosh, Delaware, Ottawa, Mayes, Craig, Rodgers, Tulsa, and Washington counties. Within those counties there’s home to almost 360,000 tribal members (Hoffman). The opioid epidemic is affecting the Cherokee community by not having enough funds for everyday healthcare like cancer treatments, diabetes treatment, Medicaid programs, and the child welfare cases.
“The resources of the Cherokee Nation are being spent on this crisis that otherwise should be spent on our ordinary, everyday healthcare needs which are very significant.”, says Todd Hembree, Cherokee Nation attorney general (Locker).
The Nation has also partnered with the Indian Health Services to help fund some new health programs, medical supplies, and helps supplies drugs. In 2012, there were 81 incidences of infants being born with NAS in those counties that make up Cherokee Nation (SoonerCare). Over a decade ago, the drug of choice for mothers was primarily methamphetamines. Now, it’s predominantly opioids (Cunningham). Not only is the healthcare a problem, but it is also hurting the heritage, traditions, and memories, that are handed down from each generation, and many families are being ripped apart by this epidemic.
Neonatal Abstinence Syndrome (NAS) is a group of conditions when an infant is going through withdrawal for certain highly addicted drugs, called opioids, that he/she may have been exposed to while being in the mother’s womb. Neonatal Abstinence Syndrome can affect the infants’ central nervous system and cause irritability, respiratory distress, gastrointestinal dysfunction, and autonomic dysfunction (Perry). These drugs can reach the infant by passing through the placenta to the umbilical cord which supplies the infant with food and oxygen. Once that umbilical cord is cut after the baby being born, the supply of drugs that he/she have been used to is immediately cut off. Synthetic opiates can cross the placenta more easily than semisynthetic opioids (Kocherlakota). Prenatal opioids that can be seen in a mother that has used before or has used during her pregnancy includes,
“(1) prescription pain management; (2) medication-assisted treatment for opioid addiction; (3) prescription drug misuse or use disorder; and (4) illicit opioid use (Newborn).
Those types of opioids consist of codeine, hydrocodone, morphine, oxycodone, tramadol, antidepressants, and benzodiazepine. When an infant is born with Neonatal Abstinence Syndrome, they don’t all show the same symptoms as others. This syndrome is rarely fatal, but can cause prolonged hospital stays due to how extent their withdrawal is. Some of the most common signs or symptoms are tremors, high pitched crying, sneezing, sleeplessness after feeding for a certain length of time, etc. (substance abuse). If the infant was exposed to a certain amount or different kind of drugs at the same time, while being in utero during the pregnancy, then the withdrawal symptoms could be more severe. Drugs that are used close to the time of the birth can increase the severity of the withdrawal but could also delay the onset of some symptoms (Perry). The only way to diagnose an infant correctly is by going through all the protocols at the hospital.
When an infant is born and the doctors or nurses suspect that the mother has used drugs during the pregnancy or knows that the mother is a regular drug user they will test the infant for that specific drug. But before they go through with they do screenings, they go through the 4Ps, parents, partner, past, pregnancy with the mother. They test the mother if she shows signs:
“(1) presenting at the hospital far from home, with no reasonable explanation; (2) No prenatal care; (3) Premature birth or labor; (4) Physical signs of substance abuse; (5) Self- reported substance use and/or history of abuse; (6) Previous positive test during pregnancy” (Substance).
If the infant is preterm he/she may demonstrate fewer signs of withdrawal due to the lack of neurologic immaturity, whereas therapy is normally administered to the infants that reached full term (NAS). Even though Neonatal Abstinence Syndrome is a clinical diagnosis, the hospital staff confirms their suspicions with a toxicology screening. There are several ways to perform a toxicology screen on an infant there is urine, meconium (first stool sample), hair follicle, or umbilical cord tissue (Wiles). Some of these tests/screening can be easier, more noninvasive, and can produce test results faster than others. Not each test/screening are going to come back positive each time due to what kind of drug may be in the infants’ system. For example, natural opioids are easily detectable in urine and meconium, while semisynthetic and synthetic opioid drugs are not (Kochlatoka). Even though these tests give the hospital a diagnosis and a direction to start towards treatment, those screenings come with a price. After all the screenings are processes and the results come back, hospitals then monitor the infant in the NICU.
The nurses and staff use the Finnegan Neonatal Abstinence Severity Score or known as NAS scoring chart to monitor the infant to see it the infant is getting better or getting worse. The Finnegan Neonatal scoring chart is the common tool used to see how severe the infants’ symptoms are and what they could be. Doctors and hospital staff have to go through careful training to know how to use these scoring chart, so they know how to evaluate and manage the infant with its’ withdrawal. The scoring process is normally performed after feeds, at 3-to-4-hour intervals, and when the infant is awake (Kocherlatoka). Since these protocols have been in place, more babies have been diagnosed faster and can be started on a pharmacological or a non-pharmacological treatment to try and help the infant wean off whatever drug they are addicted to.
When treating infants with Neonatal Abstinence Syndrome, every hospital has the option of using pharmacological or non-pharmacological methods of treatment. Non-pharmacological treatments are usually the first option that the hospital staff tries to push for an infant that has a mild case. There’s an assortment of methods when leaning towards the non-pharmacological method. There’s swaddling, music therapy, massage therapy, and kangaroo care (Kocherlatoka). Swaddling is one method that is normally seen and helps contain the infants’ movements when they may be having a withdrawal episode. It also mimics the comfort of being inside the womb. Another method that is being seen tried in infants with Neonatal Abstinence Syndrome is music therapy. Dr. Dawn Forbes is a neonatologist at Norton Women’s & Kosair Children’s Hospital in Louisville, Kentucky. After seeing a significant spike in numbers in 2016, they started up the music therapy program. They use a specially pressurized pacifier that plays music. The caregiver just gradually adjusts the pressure level, which forces the infant to start sucking. The more and harder the infants do, the longer the music plays (Flores). With that pacifier being specialized, it is training the infant to try and sooth itself down and it gradually improves some of their symptoms. Michael Detmer, one of the NICU music therapists said, “I use music and live-singing, patting and rocking beats to match the infants’ behavior state” (Flores).
One method that is commonly overlooked is breastfeeding. Obstetricians and lactation specialists have endorsed breastfeeding among the opioid-addicted mothers. The reason that these specialists are pushing breastfeeding is that breastfeeding may decrease the incidence of NAS, as well as the need pharmacological treatment, and the length of the hospital stays (Kochlatoka). Breastfeeding allows the infant to bond with the mother if they choose to keep the infant, but it also helps with the withdrawal symptoms. With this method, it can help enhance the mothers’ maternal instincts and also help avoid the process of pharmacological treatment. At W.W. Hastings Hospital in Tahlequah, Oklahoma is one of the main hospitals in Cherokee Nation, they don’t normally do the non-pharmacological approach. Stated by Cherokee Nation’s attorney general, Todd Hembree, “We have addicted mothers and father who don’t give a damn about what their children carry on” (Hoffman). Hastings mainly just goes with the pharmacological approach even though it hurts them financially in the long run.
Normally pharmacological would sound like the better option over non-pharmacological, but it all depends on the severity the infant. Pharmacological methods are only required when
“(1) supportive therapy fails to control the signs of withdrawal; (2) withdrawal scores are still high; (3) serious symptoms are observed; (4) withdrawal is associated with severe dehydration because of diarrhea and/or vomiting. Delays in the administration of pharmacological therapy are then associated with higher morbidity rates and longer hospital stays (Kochlatoka).”
When infants are put on a pharmacological treatment plan there’re many medications that could be used but, not one single medication could be the one for that certain patient. One of the most commonly preferred medication is morphine. When the infant is given morphine, it decreases the incidence of seizures, will improve feeding, eliminate diarrhea, decreases agitation, and can even control some of the severe symptoms (Kocherlatoka). However, if morphine is being used, it can cause the infant to have a longer hospital stay. Just like the Finnegan scoring chart, morphine is given to the infant every 3-4 hours, due to its’ short half-life. People think that a morphine treatment is going to make the infant more addicted, but actually, it’s relatively safer and more suitable for the management of those infants with NAS (Kocherlatoka). An alternative to morphine is methadone, which can be used along with other medications such as phenobarbital. Even though phenobarbital is used more as a therapeutic agent for those infants with NAS, but is also used as an adjunct to morphine and methadone (Kocherlatoka). In Cherokee Nation, the pharmacological method is used more than the non-pharmacological. Dr. Talara Taylor, a former W.W. Hasting Hospital labor, and the delivery nurse took care of an infant that was not doing so well during the night. To try and stabilize the infant from getting worse she gave phenobarbital to him/her and was able to keep him in good margins till they life flighted him/her to Tulsa. Even though these infants have to go through this, the flip side of it is that it all costs money.
As everyone knows that when an infant is needing extra care at the hospital, the expenditures can add up quickly with all the medications being used, medical staff, and monitoring. The cost is different between normal healthy infants and the ones that are born with NAS. A normal healthy infant normally stays in the hospital for 1-2 days. The cost on average is around $8,802, that’s with the prenatal, delivery, post-partum healthcare, and the hospital stay for a healthy infant (Fetters). That also varies due to where you live, whether you may have complications, whether you have a natural birth or a c-section, as what kind of healthcare you may have. From 2000 to 2012 there were an estimated 21,732 infants that were born with NAS in the United States (Dramatic). These infants are usually born with a low birth weight and could possibly have other complications which mean the infant will need more hospital time. Infants with NAS on average stay in the hospital for 16-17 days in Figure 1. With the cost estimating it be around $66,700, with the majority of some charges were paid with the help of Medicaid programs (Dramatic). Also, those prices with an infant with NAS can change due to how severe the case is or if that infant can wean off the drug fast enough.
Infants with NAS can get pharmacological treatment with different kinds of charges. Mentioned earlier, the drug screening process happens after the infant is born. The price for urine screening costs $300-$550, meconium cost $250-$500, umbilical cord costs $400-$800 (Wiles). But there are also different charges when certain drugs like morphine, methadone, and phenobarbital are used to help the infant wean off. The average wholesale price for the first day of the pharmacological treatments is morphine ($0.07), methadone ($0.03), and phenobarbital ($0.42) (Wiles). In Cherokee Nation, if the infant is on a pharmacological treatment and Hasting’s running out of options or even beds, that infant will be life flighted to St. Francis Hospital in Tulsa, Oklahoma. Hastings has a level 2 NICU which is not equipped for long-term care like St. Francis is. Another thing that hurts the community is not just the cost and everyday health care, but foster care is also raising an issue.
Across the United States, foster care is full of children who have special needs or who need someone to love them forever. In Oklahoma the state provides SoonerCare to those mothers who qualify. In 2012, there was 194 infants treated for NAS with 122 mothers on SoonerCare with those children. While 72 mothers didn’t have SoonerCare at that time (SoonerCare). The enrollment of SoonerCare members is increasing, but the number of NAS cases among SoonerCare members may increase. In the Oklahoma statue it states that,
“Every physician, surgeon, or another healthcare professional including doctors of medicine, licensed osteopathic physicians, residents, and interns, or any other health care professionals attending the birth of the child who tests positive for alcohol or a controlled dangerous substance shall promptly report the matter to the Department,”. (Substance).
Cherokee Nation itself has a major problem with the foster care system. With many Cherokee children and infants being drug dependent, there aren’t enough tribal members to care for them, whether their parents are trying or if they were abandoned. In 1978, the Federal Indian Child Welfare Act (ICWA) was passed to ensure that Indian tribes remain intact and the families within that tribe stay connected to their individual family members and community. There are more than two-thirds of Cherokee children who need foster or adoptive homes. Two ladies that have spoken about this issue is Chrissi Ross Nimmo, Cherokee Nation’s deputy attorney general and Nikki Baker Limore, the head of Cherokee Nation Child Welfare Services. Both women state on different articles that, “There are not enough foster homes, so they are placing those children into non-Cherokee homes.” (Cunningham & Saul). In the ICWA there are three placement preferences that they always try to shoot for: within the child’s extended family, within the child’s tribe, and within another federally recognized tribe. Around 40 percent of the cases that have been handled by Limore has involved opioid abuse (Saul). The reason they are pushing to put the infant in a Cherokee home is so that they don’t lose their heritage or language. Another lady that has a hand in placing children into foster care is Crystal Bogle, a Cherokee Nation investigator. Once an infant comes back positive for opioids then Cherokee Nation immediately takes that infant into custody, where it will stay until the mother gets clear of drugs, if the mother decides to get clear. Sometimes if the agency knows that the foster parents are going to help wean the infant, the hospital will send little morphine drips with the family to have them use if needed. It is very difficult for the agency to find a good foster home for these infants with NAS.
I personally had family friends who are Cherokee, adopted two siblings within the Cherokee Nation. They were given a 13-month-old boy and a 6-week-old girl. With the little background they had on the mother, it was said that she took heroin the day before giving birth to the girl. The doctors told my friends that she may have slight withdrawal symptoms. A couple of weeks later the little girl had a little episode where she tensed up and my friend was not able to help her relax until the episode passed. She was not given any medication due to the new parents didn’t have her medical records yet. Now at being 8-9 months old she is in and out of the hospital all the time due to respiratory issues.
There was another case where the infant wasn’t able to go to a native home. The three-day-old infant who came back positive opioids and was allowed to go home to his/her mother. But when the social workers got there they saw drugs and immediately took the infant away. For hours they tried contacting the next acceptable relative, but was unsuccessful. So, the last resort was to wake Ms. Nathalene Dixon, a non-Indian foster parent early in the morning, and asked if she could take in this infant. Between the years of 2015-2016, Ms. Dixon had taken in about a half-dozen Cherokee children (Hoffman). Seeing how this can affect an infant, is very heartbreaking and takes some really strong individuals to handle such responsibility.
Now that it is affecting the traditions and the culture of the Cherokee community the attorney general has put out a lawsuit towards some of the top drug distributors like Walgreens, CVS Health, and Walmart, and the three largest pharmaceutical distributors like Amerisource Bergen, McKesson, and Cardinal Health (Locker). The lawsuit is supposed to work in two ways by reimbursing the nation for the costs associated with the epidemic, and discouragement. Cherokee Nation’s attorney general isn’t the only one taking action, there are attorney generals from 41 other states that have taken similar forces. This lawsuit was taken to tribal court instead of state court. Some of the pharmicies mentioned in the lawsuit are speaking up and saying that a tribe personally cannot sue those companies in tribal court. The reason this case is filed, is because the Cherokee community is all about defending their identity and survival as a tribe. A rulling is expected soon and while the lawsuit is waiting to go to tribal court, doctors are trying to help matters by setting up suboxone clinics.
Suboxone is a drug that eliminates opioid withdrawal, and is now more available to due to opioid epidemic. It provides relief for patients who are tackling their addiction. Suboxone contains two drugs that fight chemical dependence: naloxone and buprenorphine hydrochloride (Suboxone). These two drugs work together to create guards around the receptors within our brain that the opioids normally attack. The naloxone creates severe withdrawal symptoms, and the buprenorphine hydrochloride controls pain and eases cravings. The closest clinic from the capital of Cherokee Nation is in Oklahoma City and patients can chose from 30 doctors that have been approved by the Substance Abuse & Mental Health Services Administration (Suboxone). These clinics are not necessary for the infant, but more for the mothers who are wanting to be in their child’s life, or to get clean for the sake of their future child if they are already pregnant.
One Cherokee Nation doctor at Wilma P. Mankiller in Stilwell is making her repeat users sign a doctor patient contract. Because those people who are repeat user go to multiple doctors and get different prescriptions and either get the pills or they will sell the prescription and those people will get the pills for themselves. The reason she is having them sign a contract is to make sure that they are trying to get better. Before every visit she will make them take a drug test just to see if they may be using again or have used lately. She is one of those doctors that will not hesitate one bit to cut you off from all supply even though she knows that he/she can go out and buy some drugs or prescription, but it just clears her mind that her name isn’t going around the town or counties.
Neonatal Abstinence Syndrome is a huge problem today here in the U.S., and the number of infants being born with this condition is increasing. There’s also an even bigger problem within the state of Oklahoma, and it just keeps getting worse as the days go on. Within the state of Oklahoma, the largest Indian tribe is also being affected. The Cherokee Nation is losing its culture, traditions, and language due to this epidemic that is causing economic loss as well. Even though the hospitals within the Cherokee Nation are not equipped for some of the cases that pass through their doors, they do all they can to help that infant with pharmacological treatments. With doing that some of the money that could go to everyday healthcare like cancer treatment, diabetes treatments, or even a radiology treatment. The Nation is taking action on trying to fix some of the problems that are happening. They have filed a lawsuit, but while that is taking a slow start, suboxone clinics are being started to help those mothers who are already addicted and what to quit, and there are possibly more doctors starting to use the contracts more and more. Hopefully, sooner rather than later there will be an impact, and this epidemic will be decreasing in numbers instead of increasing.