Scroll to the end of the story to see interactive graphics that provide insight into the opioid crisis here in our area.
At Fauquier Hospital, doctors and nurses have become painfully familiar with the challenges of caring for addicted mothers and their babies. In 2015, in fact, the rate of infants who went through drug withdrawal in Fauquier County was four times the state’s rate. “We’ve had as many as five addicted babies in here at one time,” said Jeremy Challiet, a pediatrician at Fauquier Hospital. “The nurses need a break when that’s all they’re dealing with, day in, day out. It certainly increased stress.”
Mothers sometimes ask Culpeper Police Chief Chris Jenkins to arrest their children. It’s the only way to save them, they tell him, because in jail, their sons or daughters can get the treatment they need. But, as Jenkins points out, the notion that inmates have access to life-changing drug rehab programs is “nowhere near the truth.”
About 91 percent of the people at the Prince William County Adult Detention Center are either in jail on a drug charge or have admitted to having a substance abuse problem, according to Maj. Amanda Lambert, director of support services. “We’re seeing more first-time offenders than ever before.”
Earlier this year, officials in Rappahannock County scrambled to launch a recruitment campaign for foster families because only one was available in the entire county. As a result, children needing foster care were being sent out of the county to more urban areas as far away as Richmond and Roanoke. Juvenile and Domestic Relations Court Judge Melissa Cupp said about half of Rappahannock’s foster placements last year “had an addiction component.”
These are just a few of the many ripple effects of the opioid crisis, an epidemic that has not just claimed more than 700 lives in Virginia’s Piedmont region during the past decade, but has also shattered families, taxed law enforcement and social services, stressed first responders and health care professionals and shredded the fabric of communities that never saw it coming. And, for the generation of children being born to addicts, or into families with opioid abuse, some true ramifications may not be known for years.
“Most people don’t realize the impact it has had on our community,” said Culpeper’s Chief Jenkins. “But this has touched almost everyone.” Jenkins knows how deeply. In 2014, his 26-year-old son, Jordan, who had become addicted to opioid medications, committed suicide.
Babies in withdrawal
The high-pitched cry of a baby going through opiate withdrawal is a disheartening sound. With their nervous systems agitated and their brain receptors more sensitized, such infants often struggle to eat and fall asleep. They tend to have lower birth weights. They can sweat a lot and become dehydrated. They’re jittery and highly irritable, and bright lights or the sound of a TV or even multiple people talking can upset them. Sometimes they scratch their faces.
“There’s more brain activity during withdrawal,” said Susan Werner, a pediatrician at Culpeper Medical Center. “Like the brain healing after a concussion.”
Known as neonatal abstinence syndrome (NAS), it’s a particularly disturbing side effect of the opioid epidemic. Fifteen years ago, roughly one out of 1,000 babies was born with NAS, according to the National Institutes of Health. Now, in many rural communities, it’s closer to one in 100.
Data compiled by the Virginia Department of Health shows that births to addicted mothers peaked in Fauquier County in 2015, when they were recorded at close to 25 NAS babies per 1,000 newborns. The number has dropped since then, but in 2017, it was still twice as high as the state’s. In Culpeper County, NAS births occurred at triple the state’s rate in 2016, although they did decrease slightly last year. While the NAS rate in Prince William County has stayed below the state’s, it was still three times higher in 2016 than it had been five years earlier.
The cost of addicted infants
Because the babies often need to be medicated during their withdrawal--usually with methadone or buprenorphine -- their hospital stays can last for weeks instead of days. Sometimes, they’re there for as long as a month. Another complication is that pregnant women using addictive drugs are less likely to get prenatal care. It could be because they’re afraid their baby will be taken away from them or they simply fear how harshly they’ll be judged by a doctor. But the result can be more health problems for the newborn.
All of which drives up costs. The expense of caring for a NAS baby has been estimated as three to four times as much as for an infant born without the condition. Usually, NAS treatments are covered by Medicaid, but they’ve increasingly become a drain on state Medicaid programs. A study published in the journal Pediatrics last year estimated that NAS care added $2 billion to Medicaid costs in the United States between 2004 and 2014.
So there’s a sharpened focus on determining what kind of care works best in healing NAS newborns, according to Shannon Pursell, maternal and infant health coordinator for the Virginia Department of Health. “We’re learning that babies who used to just be given pharmacological treatment if they had mild to moderate addiction symptoms are actually doing better with ‘kangaroo care,’” she said. “Putting the baby skin-to-skin with mom. Breast feeding. More mother-baby bonding.”
Stress at home
What happens after the mother and baby go home can be a bigger challenge. There’s the risk that they’re returning to a stressful environment, a situation that can quickly spin the mother back into the cycle of drug use. That could lead to the child being neglected or even abused.
Hospital staffs now try to better prepare the women for what can be a daunting transition to motherhood, often one with financial and emotional struggles. They’re working more closely with child protective services to ensure that the mothers are able to take on both their own recoveries and their babies’ care. Social service agencies do more of the follow-up work of ensuring that other family members are doing their part to keep the home safe and stable.
“If it’s a case where the mother is barely hanging on in the methadone clinic and the dad is still using drugs, or the mother is a single parent, you’re going to keep those babies longer until you’re really sure that everything that needs to be done for the baby can be done,” said Werner.
“This population in general can be a trying one to deal with,” said Cheryl Poelma, director of women’s health services at Fauquier Hospital. “But some families are really in a good place. They’re getting help, they’re in programs, and we’re confident that by the time the baby goes home that there’s a good plan in effect.
“Another positive we’re seeing is moms being more honest with us from the beginning,” she added. “We need them to tell us what’s really happening with them. What are they using? What’s their pattern? When they’re forthright, we can get help quicker and more lasting results. And, as health professionals, I also think we’ve really grown in terms of not being judgmental.”
Many pediatricians think that NAS babies may face more potential harm after opiate withdrawal than during it. To date, not enough research has been done to establish a clear physiological connection between NAS at birth and developmental problems later.
“In my experience,” said Dennis Rustom, a physician at Piedmont Pediatrics in Warrenton, “most of the longer-term effects are social and psychological, rather than physical.”
One big risk factor is the mental health of the mother, for whom drug use may have started as a form of self-medication. Or, as Rustom put it: “The impact on the baby may be wrapped up in why the mother became opioid-addicted in the first place.”
Another is the toll addiction takes on a family’s finances, sometimes in less obvious ways. “Parents who are addicted to opiates are often not able to pay child support,” said Judge Cupp in Rappahannock. “Whether it’s because they can’t work or function, or because they’re trying to get sober, and when they’re in treatment, at least at the beginning, they may not be able to work. We’ve also had cases where the person responsible for child support died.”
Then there are the destructive ripples it can stir up in families. “One thing that’s really challenging is how deep this goes in affecting families—grandparents, other children, aunts and uncles. It’s a far-reaching thing that’s not easily solved,” said Poelma.
She explained, “It’s not like we can say, ‘Take this medication and you’ll be fine.’ It’s something they’ll be dealing with the rest of their lives. You have little babies who start their lives in withdrawal, and then they’re going to grow up in a family that needs help. The hard part is seeing the devastation it brings to families, and knowing how hard it is for someone to pull themselves out of it.”
Sometimes they don’t. It’s not unusual for the parents, overwhelmed by their new responsibilities, to backslide into their old habits as users. Ultimately, a parent may realize he or she needs more intensive treatment in a residential facility. Either way, someone else ends up caring for the baby.
More often than not, it’s family members. Often, the grandparents or an aunt and uncle rush in to take on the child-rearing. Other times, child protection services reach out to relatives, in line with the priority of keeping families together.
Moving a child isn’t always the direct result of substance abuse, but the opioid epidemic has also had an impact there. While the number of cases handled by child protection agencies hasn’t changed dramatically, their nature has, according to Marisa Sori, prevention supervisor in the Culpeper Department of Human Services.
“In the past, we focused more on truancy or food issues,” she said. “Now we’re seeing more abuse, including more sexual abuse and more drug abuse. That’s the one that’s increased the most. You’re seeing more cases where parents are putting their children as risk. We’re swapping truant kids for these more intense situations.”
Martha “Mimi” deNicholas, program manager of Family and Child Services in Fauquier County, has witnessed the same trend. “The cases are certainly more complex now,” she said. “You’re dealing with mental health and how it’s related to so many issues. Making a decision to return a child to a family can be very complex.”
Finding foster care
When keeping a child within a family isn’t an option — such as when the home situation isn’t considered safe — social services turn to foster care. Ideally, they can place kids with a foster family that’s been vetted and has received training and a home study. But maintaining an ample roster of foster families has been difficult, and they’ve had to instead send children to group homes, often far from their own homes.
That’s particularly true in places like Rappahannock County, where the combination of aging demographics and the long work commutes of younger residents has kept the number of willing foster families in very short supply. In fact, by last fall, only four of the 23 children in foster care were actually living in Rappahannock. Others had to be placed in group homes or residential facilities in more urban locations hundreds of miles away.
That prompted Judge Cupp and Jennifer Parker, director of social services for Rappahannock County, to jump-start a foster-family recruitment campaign, primarily at churches in the community. It paid off. An additional seven families received foster-care training earlier this year.
That gives Parker’s office some cushion to deal with crisis situations when a kid is removed from a home in the middle of the night. “I hope I never have to see another child sleep on our floor until we can find a placement for them,” she said.
It also eases some of the pressure Rappahannock and other counties are facing as a result of Congress passing the Family First Prevention Services Act last year. The law doesn’t go into effect until October, but it’s meant to discourage foster placements in group homes by limiting federal funding support to only two weeks. Any costs beyond that period would have to be covered by the local government. Instead, the law will make more money available for mental health services and other therapy to help former addicts adjust to parenthood and hold their families together.
That approach to child welfare has been a challenge in Rappahannock, according to Parker, in part because people usually need to travel outside the county to get access to those counseling services. She is hopeful that the recent addition of a person dedicated to handling substance abuse cases—modeled after a similar program in Fauquier -- will help change that. By her estimate, at least 75 percent of the cases for the 27 Rappahannock kids now in foster care involve substance abuse, including alcohol.
A social safety net
Foster families receive between $500 and $700 a month to help cover the cost of care. They also have access to social workers and counselors. By contrast, those who provide what’s known as informal kinship care — usually the grandparents — often plunge back into parenting with no financial support and only a vague notion of what they’ve taken on.
Yet, to a large degree, they’ve become the social safety net of the opioid epidemic. Without them, child welfare services around the state would likely be overwhelmed. But the impact on their own lives is often profound.
“Most go to grandparents, although in some cases, a baby ends up with great-grandparents,” said Lisa Peacock, director of Culpeper Human Services. “Parenting has changed so much since they were parents. There’s all the access to the Internet. What happens at school has changed.
“Think about it,” she added. “You’re living on a fixed income, just getting your Social Security check. And now you’re raising your grandchild or great-grandchild. And you have your own health issues, and you have to worry about their future if something happens to you.”
Then there’s the anger. Chris Connell knows all about the anger. A little more than six years ago, she said, her daughter started using heroin soon after she had a baby. It wasn’t long before she declared herself a “bad mom” and handed the infant to a friend. Then she overdosed.
She survived, but Connell and her husband, then in their 40s, took in their grandchild. The child has lived with them since.
“I was a terribly angry parent with my daughter,” said Connell, who is now a recovery coach for SpiritWorks in Warrenton. “I asked her, ‘Why can’t you get clean for this baby? Why can’t you step up and be a mom? Why can’t you do the right thing?’”
In time, Connell joined Families Anonymous, a 12-step program for relatives and friends of addicts. “I was in a mess,” she said, “and decided I needed to find a way to recover so that I’d be a better role model for my granddaughter.”
Her daughter and granddaughter have no contact, she said.
“Our granddaughter hasn’t asked a lot of questions. We tell her she’s a gift from God and she seems content with that right now,” she said. “We’re in counseling for how we deal with telling her about her mother. Because I’m sure there’s going to be a lot of questions.”
But Connell is certain about one thing. She now believes she was wrong to condemn her daughter.
“I finally realized that it wasn’t her choice to act like this. It’s a disease. It’s hijacked her brain.”
10 Ripple Effects
The impact of the opioid epidemic goes far beyond overdose deaths. Roll over the numbers to see some of the ways it has affected communities.
Opioids and Babies
Since 2000, the rate of babies who go through drug withdrawal after birth—a condition known as neonatal abstinence syndrome (NAS)—has skyrocketed by more than 400 percent in the U.S., according to the Centers for Disease Control (CDC).
At the turn of this century, only about one out of every 1,000 infants was born with NAS; now, in communities particularly hard hit by the opioid epidemic, it’s typically seven or more babies per thousand hospital births.
In Virginia, the NAS rate has risen steadily, climbing to more than eight newborns per thousand births through the first half of last year, according to the Virginia Hospital and Healthcare Association.
In this region, the NAS rate in Fauquier County has consistently run above the state average, particularly in 2015 when it was four times higher. In recent years, the NAS rate in Culpeper County has also stayed well above the state’s. In counties where there are not many births, such as Rappahannock, the rate can fluctuate widely from year to year.
Opioids in Virginia's Piedmont:
A Deadly Decade
From 2008 through the end of last year, 859 people in Virginia’s Piedmont region, including Prince William County, died from drug overdoses. In 4 out of 5 of those deaths, opiates were responsible.
Beginning in 2016, the number of opioid deaths jumped dramatically—more than 40 percent. A big factor, according to law enforcement officials, is the spreading use of drugs laced with fentanyl, a synthetic narcotic that’s 80 to 100 times stronger than morphine. From 2016 through 2018, almost 78 percent of the opioid deaths in Fauquier County involved fentanyl. The rate of deaths was only slightly lower in Culpeper and Prince William counties—about 67 percent.