Every other week Cassidy Linnemeier carpools with a friend to their OB-GYN in Indianapolis from Seymour Indiana, where they live. The drive is about an hour and 20 minutes with traffic.
They drive this far because they can’t find a doctor nearby who will prescribe the addiction medicine they need to keep them healthy during pregnancy — and who also takes their insurance, a Medicaid plan.
The medication is called buprenorphine. It curbs cravings. Combined with therapy, Linnemeier says the medicine has helped her stop using, hold down a job, and take care of her kids.
“As long as it’s taken the way it’s supposed to be taken and treated the way it’s supposed to be treated it’s an amazing thing,” she says.
But when Linnemeier got pregnant several months ago, she says her doctor at the time dropped her and she struggled to find a provider who would treat her addiction. “I’ve never went through so much hassle to get something that I need, that my doctor agrees that I need,” she says.
Doctors who can prescribe a medication for opioid addiction, and accept Medicaid, are already scarce. But even fewer will treat pregnant women. At this most vulnerable time, when both mother’s and baby’s lives are at stake, some doctors even drop their patients. It’s caused by ungrounded fears of treating pregnant women, says Elizabeth Krans, assistant professor in the Department of Obstetrics, Gynecology & Reproductive Sciences with the Magee-Womens Research Institute. Krans studies buprenorphine treatment adherence in opioid dependent pregnant women.
“Everyone is just nervous about [the] neonatal impact of medications regardless of tons of research on the safety of a lot of meds in pregnancy, including buprenorphine,” she says.
Before Linnemeier got pregnant, she had been going to a doctor about an hour from Seymour. Her doctor prescribed her buprenorphine but, she says, he gave her a warning: “He said, if we find out you’re pregnant and you haven’t told us you're pregnant already we have to discharge you.”
When Linnemeier suspected she was pregnant, she told her doctor. He gave her a two-week supply of Subutex, a version of buprenorphine for pregnancy, and discharged her, telling her, “You’re going to have to find a new doctor.”
When a women in Linnemeier’s situation runs out of the medication, it only takes hours for withdrawal symptoms to set in. She might relapse and expose her baby to infection. Or overdose.If she’s in her final trimester and starts using street drugs again, there’s also a risk of miscarriage.
It’s common for pregnant women in treatment for opioid addiction to get discharged by their doctor, according to addiction treatment experts working with this population. Dr. Tara Benjamin runs a prenatal clinic specializing in helping these women, a program of Riley Children's Health based at Indiana University, University Hospital. Benjamin says, a few years ago, more and more patients started showing up at her clinic addicted to prescription pain pills and heroin.
“What happened was we started getting patients coming into us saying ‘I was on Subutex and my doctor cut me off and I don’t know what to do,’” says Benjamin.
To prescribe buprenorphine, the active ingredient in Subutex, doctors must take an eight-hour course, and request a special waiver from the Drug Enforcement Administration. During the first year, these doctors may treat up to 30 patients. After a year, they can choose to apply to take on up to 100 patients. Benjamin is the only OB-GYN in Indiana who will treat 100 patients with addiction. Benjamin says just a handful of OB-GYNs in the state have the waiver.
Benjamin manages the load - linking patients with a social worker, therapy, and transportation to the clinic. She says you can’t just stop prescribing once a patient gets pregnant.
“If I had my way, whatever doctors were taking care of them before, would continue to take care of them,” she says. “Stopping it is the worst thing you can do.”
At the very least, she says, doctors are supposed to give patients written notice and time to find a new doctor, according to patient abandonment law. The recommended timeframe in most states is 30 days. Medical ethics guidelines warn against abruptly withdrawing care. In some cases it can be litigated as abandonment.
In fact, firing pregnant patients is not only risky, it’s unnecessary says Dr. Louis Baxter, immediate past president of the American Society of Addiction Medicine. Baxter, who helped shape national guidelines for how buprenorphine should be prescribed, says you don’t need to be an obstetrician to prescribe buprenorphine to pregnant women. Any doctor with the DEA waiver can prescribe for these women.
“A lot of physicians become fearful in that situation because they’re not fully educated, or they don’t understand how these patients should be managed,” Baxter says.
Baxter says, as long as their patient has an OB-GYN that’s aware they’re taking Subutex, the primary care physician can keep prescribing. “The fear that some prescribers have is really unfounded,” he says. “There’s very little risk.”
He says he thinks the eight-hour course that doctors take to get the waiver should be updated to include discussion of treatment during pregnancy.
After her doctor dropped her, Cassidy Linnemeier rushed to find a new doctor before her two-week supply of medicine ran out. In total, she went to three doctors before she found Dr. Benjamin’s clinic in Indianapolis. The first fired her. The second refused to treat her. The third didn’t prescribe buprenorphine. By the time she met Dr. Benjamin, she was rationing her tablets, taking less than the recommended dose each day to stretch it out.
“Thank God I had enough to last me,” she says. “At least I wasn’t withdrawing.”
But Linnemeier is happy she landed where she did. “The nurses and the doctors are amazing,” she say. “I love it.”
She says she’d hate for other women to go through the uncertainty she went she went through. She’s just thankful she and baby made it to a new doctor.
“I got to hear a heartbeat today so I know she’s OK,” she says. “And I got to see her a few days ago and everything is fine.”