On a recent fall day, I became reacquainted with the unmistakable beauty of my West Virginia hometown. Bluefield is tucked in a valley with Big Walker Mountain setting its southeastern border, and nearly everywhere you look is breathtaking.
On the surface, you might not expect to find a crisis brewing across America to be striking a rural town like Bluefield. But local economies are hurting, the opioid epidemic is growing, and together they are taking a toll on a surprising population—pregnant women and their babies.
It doesn't take much more than a stroll through downtown Bluefield or any number of Appalachian towns to see how the economic engine, once booming and driven by coal, has slowed. Bluefield's population today is just under 10,000, half of what it was in 1950.
To me, those shuttered storefronts shed light on part of the opioid crisis.
Infants Are Casualties to Our Opioid Epidemic
Even though my home state has been the undisputed epicenter of the opioid crisis, I was first introduced to it while working as a neonatologist in Michigan. I started seeing infants with opioid withdrawal, also called neonatal abstinence syndrome. Infants with the syndrome differ from most infants I care for who are born too early or with complex birth defects. While not nearly as sick, they are irritable, don't sleep well, can have trouble eating, are jittery and do require medical care.
My first reaction to treating infants with the syndrome was confusion and, if I'm honest, judgment. I wanted to understand what led so many women to use opioids during pregnancy.
Neonatal abstinence syndrome can occur when babies are chronically exposed before birth to opioids, whether their mothers are using illegal drugs or prescribed medicines. Sometimes mothers take an opioid like methadone because it can be important to treating their addiction. These medicines also increase the likelihood their infants will be born at term.
In studying the problem, it quickly became clear that the use of opioids by pregnant mothers could not be distilled down to their use at the time of delivery. Social and economic history needed to be taken into account.
West Virginia Flooded with Painkillers
There is no denying that overprescribing is a culprit in West Virginia's opioid crisis, beginning nearly 20 years ago. At one point, McKesson Corp., a pharmaceutical distributor, shipped more than 3 million pills—almost 10,000 pills a day—over a 10-month period to Kermit, West Virginia, population 400. The combination of struggling rural economies with an overabundance of opioids was explosive. West Virginia's overdose death rate is three times the national average.
The link between opioid prescriptions and overdose deaths is clear. The link between opioid prescriptions and my newborn patients was not. My colleagues and I initially focused our research on trying to understand the problem. We found that the number of Medicaid-covered infants diagnosed with neonatal abstinence syndrome had grown fivefold over the 10 years from 2004 to 2014—the rate was higher in rural communities. We explored links between women being prescribed opioids in pregnancy and an infant's risk of drug withdrawal. But as the opioid crisis evolved, this work increasingly seemed inadequate.
The opioid crisis is not just a health care problem. It is also a social problem, one that leads to newborns needing to be treated for drug withdrawal.Share on Twitter
At Vanderbilt University Medical Center we've taken care of more than 200 opioid-exposed infants in the last 18 months. When we take the time to truly listen to pregnant women using opioids, we uncover complicated narratives involving trauma and violence. It is clear that the opioid crisis is not just a health care problem. It is also a social problem, one that leads to newborns needing to be treated for drug withdrawal.
Experiences in rural communities and conversations with families led our research group at the Vanderbilt Center for Child Health Policy and the RAND Opioid Policy Tools and Information Center to analyze the relationship between long-term economic downturns, particularly in rural communities, and higher rates of newborn drug withdrawal.
Opioid Crisis Is Partly an Economic Crisis
From 2009 to 2015, we studied more than 6 million births in 580 counties across eight states, scrutinizing associations that included economic hardship and the county's rate of neonatal abstinence syndrome.
Higher rates of neonatal abstinence syndrome shadowed an upward trend in long-term unemployment, particularly in remote, rural counties.Share on Twitter
We found that higher rates of the syndrome shadowed an upward trend in long-term unemployment, particularly in remote, rural counties. Rural counties with the highest long-term unemployment rates had nearly five times the rate of prosperous metro counties, according to our paper recently published by the Journal of the American Medical Association.
Bluefield is a good example of these findings. The unemployment rate in Mercer County, where Bluefield is located, is improving but has not fallen to where it was before the 2008 recession. Rates of neonatal abstinence syndrome are high. According to a state report, nearly 3.5 percent (PDF) of infants born in Mercer County were diagnosed with drug withdrawal in 2017. That's more than four times the national average.
Of course, the medical interventions provided in hospitals and clinics are hugely beneficial in treating infants and their mothers affected by opioid use. But in listening to tales of life in small rural towns, we heard a need for a broader answer—one that addresses the need for economic development and social support that can help individuals in these communities lead healthier lives.
Stephen Patrick is director of the Vanderbilt Center for Child Health Policy, attending neonatologist at Monroe Carell Jr. Children's Hospital at Vanderbilt University and a research fellow with the RAND Opioid Policy Tools and Information Center.
This commentary originally appeared on USA Today on March 5, 2019. Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.