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Born Exposed

When Addiction Devastates a Generation, What Happens to Their Children?



Lisa Robbins and her two grandchildren at her home in Maryville, Tennessee, about an hour outside of Knoxville. Photo: Joanie Tobin/100 Days in Appalachia

Life as empty nesters was on the horizon for Lisa Robbins and her husband Brent. They had raised two children and were enjoying helping them with their two grandchildren. But in 2016, police arrested Lisa’s daughter Mollie. 

“She got caught using drugs, shooting up in her vehicle in a convenience store parking lot,” Lisa said. “And so she went to jail.”

Mollie was pregnant at the time of her arrest. Lisa said it had been months since Mollie, now 24, had gotten any prenatal care.

“At that time, she was five-and-a-half months pregnant and she hadn’t had but one visit to the doctor up to that point.”

Mollie was using heroin, meth and opioid painkillers. The family worried her drug use would put her baby at risk for neonatal abstinence syndrome or NAS, a condition where babies are born in withdrawal from drugs their mothers used during pregnancy.  

Mollie asked for help and the Robbins took her to High Risk Obstetrical Consultants, a clinic at the University of Tennessee in Knoxville that specializes in treating opioid-affected pregnant women and babies. There, Mollie received prenatal care and underwent medically supervised detox before her daughter Adaline Grace, who the family calls Addie, was born. 

“Addie was born very healthy, six-and-a-half pounds, no NAS. She did not spend a single moment in the [Neonatal Intensive Care Unit]. So, we were very blessed for her to be born as healthy as she was and then to be fully weaned [from opioids],” Lisa said.

Lisa’s daughter Mollie underwent medically supervised detox before her daughter Adaline Grace, who the family calls Addie, was born. Photo: Joanie Tobin/100 Days in Appalachia

It was April 2017. Mollie maintained her recovery for a while after that, Lisa said, but one night, she went out with the baby and didn’t come home. A few days later, Mollie’s in-laws called the Robbins to say Adaline was at their house. 

When Mollie resurfaced, police arrested her for violating her probation and sent her back to jail. Later, a judge granted Lisa, 50, and Brent, 54, custody of Adaline until she turns 18, or until Mollie petitions the court for custody.

“I didn’t want to raise another child and I feel guilty for that. But I’m a Christian woman. So I started praying and I said, ‘God, you show me what I need to do,’” Lisa said. 

Addie was born healthy with no signs of NAS. Photo: Joanie Tobin/100 Days in Appalachia

 “There was no other option but for me to take care of Adaline, to help any way I could. If it meant I brought Mollie home, she lived with us and I took care of both of them, then that’s what I was going to do,” she said. “And so now we have Adaline, and to look back, I wouldn’t change it for the world.”  

The Robbins are among the thousands of grandparents across Appalachia who are stepping in to raise grandchildren because their own children suffer from addiction, are incarcerated, or died due to a drug overdose.

Nationally, the number of children living with grandparents, relatives and close family friends has jumped nearly 18 percent over the last decade to more than 2.7 million. The increase is linked in part to the nation’s opioid epidemic, according to a report from the nonprofit advocacy group Generations United.      

East Tennessee, where Lisa Robbins is raising Adaline, is seeing a similar increase in grandparent-headed households as many communities are especially hard-hit by both the opioid epidemic and neonatal abstinence syndrome. 

“In Monroe County, it’s like 65 percent of the babies born have somehow been born drug-dependent,” said Teresa Harrill, health department director for both Monroe and Loudoun Counties. According to the East Tennessee Regional Health Office, in 2017, 67 percent of the babies born in Monroe County had been exposed to a prescription medication in utero. 

NAS and addiction are changing many families’ way of life in the region. 

“We see a lot of women that already have children, that, either their child is in state custody, or grandparents or family members are raising their children while they’re incarcerated,” Harrill said. 

The Robbins family lives in Maryville, about an hour south of Knoxville. Their white, wood-framed house sits perched atop a rise at the end of a long winding driveway not far from Great Smoky Mountains National Park. Children’s toys, freshly chopped firewood and a brick-red chicken coop sit in the yard. In the driveway, a car license plate displays a verse from the Bible, John 3:16: For God so loved the world that he gave his one and only son. 

It’s a rural area of rolling hills, two-lane roads dotted with churches, horse stables and lush farmland. 

Adaline and her cousin play in the backyard of their grandparents home. Photo: Joanie Tobin/100 Days in Appalachia

On a recent Sunday morning, the cool air reverberated with a country chorus of birds, frogs, cows and chickens. 

Lisa and her mother Linda were busy in the kitchen packing coolers for a cookout after church. 

Underfoot, Adaline, now 2 years old, padded into and out of the room, holding a sippy cup and asking for milk.  

“My job was to be a grandmother, but my job now is as a mother to my grandchild. She’s my responsibility 24/7. I’m supposed to be teaching Mollie how to be a mom, and that’s hard,” Lisa said. “God intended us to be parents as young people. I mean, I don’t know any other way to put it, but you get tired. When you’re younger you think, ‘oh, I have to clean house, I have to have it a certain way.’ But as you’re older you realize that’s not what’s important–– it’s the baby or the child.”

Lisa, whose grandchildren call her Gaga, also works a full-time job in Knoxville. Her daily commute has become her time to gather her thoughts and enjoy a moment of quiet.  

The family prays at their church during Addie’s recent dedication service. Photo: Jess Mador/100 Days in Appalachia

Church is a source of strength for the Robbins. She and Brent have been open in their church about Mollie’s drug use–– that’s how Lisa recently discovered Adaline isn’t the only child in the congregation whose mother has struggled with addiction. 

It helps to talk about it, Lisa said, hoping that by sharing her family’s experience, she could help other families touched by the opioid epidemic and help break the stigma surrounding addiction and NAS in Appalachia.

Brent said his stepdaughter Mollie’s years of drug addiction have been difficult. He recalls the anxiety and fear of countless sleepless nights spent worrying she’d overdose and die.   

“There were times [when] I wondered if we were going to have a service at a graveyard,” he said, “instead of a dedication service [for Adaline] in church.” 

Adaline plays with her great-grandfather before attending her dedication ceremony. Church is a source of strength for the Robbins family. Photo: Joanie Tobin/100 Days in Appalachia

Mollie’s addiction has also taken an unexpected toll on his family’s bottom line.   

“It’s cost us a lot of money to put her through drug rehab and stuff– $5,000 out of our savings– and I’m 54 and I’m looking forward to retiring and that’s 5,000 less dollars. That’s part of it though. If it saved her from overdosing, then it was worth it,” Brent said.

This spring, Mollie experienced another relapse and is currently back in rehab.

Despite the financial burdens and the challenges of working full-time, being a grandfather to his other grandchildren while also being a dad all over again to Adaline at his age, Brent said he wouldn’t change a thing.  

“Because Addie is my whole world. When you come home from work and you have a little girl running to the top of the steps hollering papaw, papaw, papaw,” he said, fighting back tears, “that’s something that I can’t describe.”

Brent and Lisa have chosen to take care of Adaline, but don’t hide from her that they are in fact her grandparents, not her parents.

“Sometimes she’ll call me mom and I want to correct her because I want her to realize her mom’s as important to her as I am,” Lisa said. “And, of course, selfishly sometimes I want to be ‘mom’ but I can’t. I have to draw the line.” 

Lisa and Brent both stress they hope Mollie will one day get back on her feet and be ready to parent Adaline full-time. For now, they’re focused on raising their granddaughter as Mollie continues to work on her recovery. 

This story is part of the series Born Exposed, exploring access to medical and rehabilitative care in Appalachia for opioid-affected women and their babies. Born Exposed is a project of 100 Days in Appalachia, West Virginia Public Broadcasting and the Ohio Valley ReSource.

Born Exposed

Inside Appalachia: Thousands of Children Are Born Exposed to Opioids. These People Are Trying to Help.



Pediatric Nurse Practitioner Amber Knapper meets with a family at Dr. Towers' clinic. Photo: Joanie Tobin/100 Days in Appalachia

This episode of West Virginia Public Broadcasting’s podcast Inside Appalachia was produced in collaboration with 100 Days in Appalachia and the Ohio Valley ReSource as part of the collaborative reporting project Born Exposed. Read the full series here.

This article was originally published by West Virginia Public Broadcasting.

This week on Inside Appalachia, we’re dedicating our episode to all the children who are affected by substance abuse before they’re even born. Neonatal Abstinence Syndrome (NAS) is a topic that is heartbreaking, but critically important for us to spend some time understanding. The stigma that follows mothers, and their unborn babies, is keeping them from getting the prenatal care, and help for recovery, that women across our region desperately need. 

listen to the episode

But there are stories of hope and resilience among those grappling with the fallout from the opioid epidemic. Not all children who are born exposed to drugs show signs of NAS. And researchers still don’t know what the long term impacts will be, if any. Each case is unique. What we do know is that forming loving relationships with caretakers helps children be more resilient. “All children benefit from stable, safe, and nurturing relationships and environments,” according to a 2017 report by Child Trends. “However, these relationships and environments are particularly important for young children who have experienced trauma. Their presence and stability can help children recover from past trauma and develop the skills to cope and thrive,” the report said. 

In This Episode:

The number of babies across the country who suffer from NAS has increased in the past several years, according to national and state health officials. Those reports indicate that the numbers are among the highest in central Appalachia. Five out of every 100 babies born in West Virginia have NAS — that’s up from three percent in 2013. In 2016, there were over 1,200 babies born with NAS in Kentucky. That’s more than 100 cases each month. 

Some Women Say Doctors Turned Away

Cayden’s mother Callie Relford, 29, struggled with addiction for years before her daughter was born. Photo: Joanie Tobin/100 Days in Appalachia

The stigma associated with addiction often makes it difficult for pregnant women struggling with substance use disorder to get the prenatal care they need. Producer Jess Mador reports on one East Tennessee clinic that’s pushing for changes in drug treatment for pregnant women, in hopes of keeping more babies from coming into the world with NAS.

“They don’t trust anybody,” Emily Katz said. Katz is a substance abuse coordinator with High Risk Obstetrical Consultants in Knoxville, Tennessee. “They’re embarrassed, and so many times we have heard from them, ‘you’re the first person that would listen’ or ‘you’re the first person that I’ve told this to.’”

Doctor’s Don’t Agree On Best Practices

And we hear from doctors and medical experts across central Appalachia, as they discuss the protocols to best treat for the best way to care for these moms-to-be and their babies. But as Kara Lofton reports, “standards” can still vary from state to state, facility to facility. 

Foster Care And Education 

Despite so many obstacles, like trauma, and the physical impacts of being born exposed to drugs, children can be resilient. But helping them means getting them into a stable, loving home. How does the opioid epidemic affect the foster care system? And how are teachers impacted by families touched by addiction? Those stories and more in this episode of Inside Appalachia.  

Adaline plays with her great-grandfather before attending her dedication ceremony. Church is a source of strength for the Robbins family. Photo: Joanie Tobin/100 Days in Appalachia

West Virginia Public Broadcasting’s Glynis Board guest hosts this episode.  She closes the show with these personal remarks:

“Data have revealed there is a window of opportunity where women seem to be able to access incredible strength and motivation to overcome their battle with substance use disorder. Strange as it sounds — within the struggle these women face lives a kind of hope for our entire region, that we can help each other and be inspired by each other to overcome this crisis. Maybe we can even discover, and begin to deal with, some of the root causes of addiction that so many of our friends, neighbors, sisters and mothers face. Maybe. We like to dream big here Inside Appalachia.” — Assistant News Director Glynis Board, West Virginia Public Broadcasting.

Born Exposed is a project of 100 Days in Appalachia, West Virginia Public Broadcasting and the Ohio Valley ReSource. The OVR is supported by the Corporation for Public Broadcasting and West Virginia Public Broadcasting. This episode also included stories from StoryCorps and Side Effects Public Media. 

Roxy Todd is the producer. of Inside Appalachia, Eric Douglas is the associate producer with executive producer  Jesse Wright. He also edited the show this week. The audio mixer is Patrick Stephens.

You can find the show on Twitter @InAppalachia.

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Born Exposed

Pregnant Women Struggling with Addiction Say Doctors Turned Them Away. This Appalachian Clinic Is Changing That.



Maternal-fetal Medicine Physician Dr. Craig Towers sees hundreds of women affected by opioid addiction at High Risk Obstetrical Clinic in Knoxville, Tennessee. Photo: Jess Mador/100 Days in Appalachia

One-month-old Cayden wakes with a fierce cry and clenched fists as a nurse places her on a metal scale to check her weight. When she was born, the infant dressed in tiny pink socks, flowery leggings and a bright yellow polkadot top weighed 6 pounds, 7 ounces and was at risk for neonatal abstinence syndrome. 

“Have you noticed any tremors, tight muscles?” Pediatric Nurse Practitioner Amber Knapper asked Cayden’s mother. 

Tight muscles and tremors are among a long list of symptoms connected to neonatal abstinence syndrome, commonly known as NAS, a condition where babies are born in withdrawal from opioid drugs their mothers used during pregnancy. 

Other symptoms can typically include seizures, diarrhea, irritability, fever, high-pitched and excessive crying, difficulty breathing, poor sleep and difficulty feeding. Babies exposed to opioids in utero could also be at risk for long-term developmental and educational delays. 

The clinic is tracking Cayden’s progress as part of a long-term study investigating the impacts of NAS. Photo: Jess Mador/100 Days in Appalachia

This is Cayden’s first checkup since leaving the hospital’s newborn intensive care unit, and Knapper examines the baby closely, asking about her appetite, her breastfeeding and sleep patterns. 

“The big thing I want to do today,” she said, “is, I want to get her down to a dry diaper, I will get her weight, length, measure her head and just see how much she has grown.” 

Cayden showed no signs of NAS at birth. Nonetheless, this is the first of many follow-up visits that she’ll undergo over the next three years. 

“Not only do we want to see all of the babies back that did have NAS and were in the NICU [Neonatal Intensive Care Unit] and treated, we also want to see these babies that did not have NAS, and we want to see how well they do– we want to compare,” Knapper said. 

Knapper is part of an expert team at this University of Tennessee Medical Center clinic in Knoxville called High Risk Obstetrical Consultants. The clinic is tracking Cayden’s progress, and the progress of more than 600  other children, for a study investigating the long-term impacts of NAS in babies. 

Pediatric Nurse Practitioner Amber Knapper meets with a family at Dr. Towers’ clinic. Photo: Joanie Tobin/100 Days in Appalachia

“We’re checking to make sure that they’re meeting all their milestones, developmental milestones– motor skills, speech, cognitive– and that they’re growing as they should,” Knapper said.  

Cayden’s mother Callie Relford, a petite blonde in knee-high brown boots and blue jeans with her hair pulled back into a high ponytail, struggled with addiction for years before her daughter was born. Rocking the baby to sleep in her arms after the checkup, the 29-year old recalled her addiction to pain pills, which eventually led her to homelessness. 

“There was no food to eat. You didn’t know what was going to happen the next day, if you was going to make it, if you was going to have something to eat, a roof over your head, if you was going to be able to shower. That was my life for a good six years, but a good four of it was literally living on the lake or in an abandoned house,” Relford said. “There was a lot of legal issues, I got in trouble a lot.”  

She was already pregnant when Relford’s struggles with addiction landed her back behind bars in an East Tennessee county jail on drug-related charges.  

“When I got there I was like, ‘I’m not about to have this child in jail,’” Relford said, “and so that’s why I needed to turn myself around and make sure she was OK and to keep her.”    

Today, Relford and Cayden live at a group home with other new mothers and moms-to-be who are also in recovery. 

Cayden’s mother Callie Relford struggled with addiction years before Cayden was born. Photo: Joanie Tobin/100 Days in Appalachia

She also has two other children, both boys, ages 12 and 5, who currently live with other family members. 

Relford said she’s working on getting back on her feet and maintaining her sobriety so her boys can eventually live with her full-time. 

“I know I’m going to have ups and downs, of course,” she said. “But I’m going to do the best I can to deal with them, cope with them, and do whatever it is I have to do to make sure that I don’t go back down that dark road again, and make sure that my kids have the best life that I can give them.”

It was during her sixth month of pregnancy when a jail program sent Relford to High Risk Obstetrical Consultants for her first prenatal check up. Relford worried the drugs she’d taken would hurt her baby. With the help of the clinic, she went through medically supervised detox and later, started on the medication Naltrexone to block her opioid cravings. 

Maternal-fetal Medicine Physician Craig Towers oversaw Relford’s treatment during her pregnancy. 

It was Towers’ idea in 2016 to dedicate one day per week at High Risk Obstetrical Consultants to treating opioid-affected women like Relford, with the goal of helping them get off drugs and deliver healthy babies born  free of NAS. Towers said he saw the need to create a special program after dozens of pregnant women came to the clinic seeking help with addiction.

“When I came here, I was amazed at how many patients I had in our high-risk OB-GYN clinic that were addicted to opiates, much more than I had where I was from previously at that time, which was Wisconsin. And the patients had two things: the first thing they would say is, ‘I didn’t plan on getting pregnant,’ but the other was, ‘I don’t want to be on these drugs and have my babies suffer for what I’m doing,’” Towers said. “And I would tell them, like everyone else, that it’s not recommended to taper or detox off of opiates because, in theory, it can cause a stillbirth and harm the baby and lead to a poor pregnancy outcome.”

Towers is leading several studies designed to test the safety of detox during pregnancy. Photo: Joanie Tobin/100 Days in Appalachia

Towers was advising his patients based on the American College of Obstetricians and Gynecologists’ standard of care for pregnant women.  

Eventually, he grew tired of hearing himself say the same thing over and over again, Towers said. He decided to review the medical literature on the safety of detox during pregnancy to put together a pamphlet for his patients, but was only able to find two studies on which the generally agreed-to medical advice was based. He wasn’t convinced. 

“There’s no data to say that [detox] harms the baby or results in a poor pregnancy outcome,” Towers said.

But that view could be considered controversial. In the United States, detox during pregnancy has long been seen as too risky for expectant mothers and infants. 

Most obstetricians recommend medically assisted treatment, also known as MAT, over detox for pregnant women addicted to opioids, using maintenance medications such as methadone, an opioid, to get them off of dangerous street drugs such as heroin and fentanyl. But the treatment itself still carries a risk of NAS.   

MAT has been shown to be highly effective in helping pregnant women stay off of dangerous street drugs such as heroin and fentanyl. But the treatment itself still carries a risk of NAS.  

Tennessee has been tracking NAS cases since 2013, and the state Department of Health reports maintenance medications are among the most common opioid sources of NAS in the state, which also include painkillers such as morphine, and heroin. In 2018, state numbers show 70 percent of infants diagnosed with NAS were exposed to MAT for the treatment of a substance-use disorder.

But Dr. Mishka Terplan, a professor in the departments of Obstetrics and Gynecology and Psychiatry at the Virginia Commonwealth University, said pharmacotherapy, or using medication, remains the gold standard for the treatment of opioid-use disorder in the U.S., not just in pregnancy but for all populations. Detox during pregnancy puts women at higher risk for relapse, overdose and the transmission of diseases, including Hepatitis C and HIV, he said.

“We know that the postpartum period is a time of increased vulnerabilities for disease recurrence. In many states that have been looking at this, overdose and overdose death is one of the leading causes of maternal mortality,” Terplan said, “and medication for opioid-use disorder protects against overdose and overdose death.”

Towers does follow the same standard of medically assisted treatment protocol at his Knoxville clinic, but it’s not the only option he gives his patients, it’s just the start.  

“All of my patients who come in using illicit drugs, meaning that’s not prescribed to them – they’re getting it from a friend off the street or stealing or whatever – I get them into a maintenance program of methadone or buprenorphine,” Towers said.

Towers believes what’s most important is that the women he treats who struggle with opioid addiction find a path to recovery and get off of street drugs as quickly as possible. Once they’re stable, Towers’ patients choose whether they want to detox completely or remain on medically assisted treatment for the remainder of their pregnancy. 

Towers’ clinic is located in a part of Appalachia that has struggled with high rates of addiction and overdose deaths. Photo: Joanie Tobin/100 Days in Appalachia

“Now, I have probably tapered off and detoxed over 700, maybe over 800 [patients] without a loss, knock on wood,” meaning without the loss of a pregnancy. “But we have a very strict program if they decide to do that.”

Towers is documenting these outcomes and leading several ongoing research studies designed to test the safety of detox during pregnancy. He’s hoping his results convince the American College of Obstetrics and Gynecologists that it is a safe option so that they’ll endorse the practice as an option for pregnant women. 

“All I’m asking for is that women be given the choice,” he said. 

The 2017 ACOG Committee Opinion on opioid use and opioid use disorder in pregnancy states: “more research is needed to assess the safety (particularly regarding maternal relapse), efficacy, and long-term outcomes of medically supervised withdrawal.” 

Towers acknowledges relapse remains a real concern. To help prevent it among his patients, the clinic provides a range of inpatient and outpatient services designed to support women throughout their pregnancies and after their babies are born. 

Offering medical, prenatal, pediatrics and mental-health services all in one place is critical for this high-risk patient population, Towers said, because many patients do not have a driver’s license or access to a car. 

“Almost all the women who don’t show up to my appointment will call and apologize and reschedule because they don’t have a ride.” 

The clinic is working with a far-flung network of advocates and nonprofits across the East Tennessee region on an effort to increase transportation options for women at risk of delivering babies with NAS. They want to make it easier for these women to keep their prenatal and addiction-treatment appointments. 

The need is urgent, Towers said, because according to the data he has collected, exposure to opioids in utero can potentially result in long-term issues for children. Towers recently published research suggesting some babies exposed to opioids, including both prescription drugs, like buprenorphine and methadone, and street drugs such as heroin, will experience developmental delays.

“There is a subset of babies that potentially have smaller head sizes, they have behavioral health issues, some of them have cognitive problems, some of them have visual dysfunction,” Towers said. “And we don’t know why some babies don’t exhibit that problem and others do.”

But the long-term effects of NAS are still subject to debate in some corners of the medical community. Towers said it could take another decade before researchers fully understand the condition’s impacts on babies and children. 

Clinics like High Risk Obstetrical Consultants that offer pregnant women both a detox option and medically assisted treatment are hard to find. Some of the women 100 Days spoke to described feeling judged by other doctors in the past. Many said they were turned away from medical treatment because they used drugs.  

Towers’ clinic sees hundreds of patients each year, including many who travel to Knoxville from all across Appalachia and the South for help, coming from as far away as West Virginia, North Carolina, Georgia and Alabama. Many more come from small communities across rural East Tennessee. 

The clinic’s substance abuse coordinator Emily Katz, who works closely with all of Towers’s patients at risk of delivering babies with NAS, said this population of pregnant, opioid-using women is especially vulnerable.  

“They don’t trust anybody. They’re embarrassed,” Katz said, “and so many times we have heard from them, ‘you’re the first person that would listen or you’re the first person that I’ve told this to.’”

Katz lost her own brother to an overdose not long ago. The experience informs her work with patients. 

Relationships are key to preventing relapse among pregnant women struggling with addiction— and preventing NAS in their infants, Katz said. Patients need someone to have their back through recovery from opioid addiction.

“They literally have burned either bridges with everybody or everybody in their family is actively using. So, we become like family.” 

This story is part of the series Born Exposed, exploring access to medical and rehabilitative care in Appalachia for opioid-affected women and their babies. Born Exposed is a project of 100 Days in Appalachia, West Virginia Public Broadcasting and the Ohio Valley ReSource.

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Born Exposed

This East Tenn. Program Aims to Stop NAS by Reaching Women Behind Bars



Teresa Harrill, director of the Monroe and Loudon County Health Departments, leads an NAS prevention workshop at the Monroe County Sheriff's Department. Photo: Jess Mador/100 Days in Appalachia

Heads turn as a white SUV pulls onto a narrow dead-end street and parks under a line of billboards advertising 24-hour bail bonds. On one side of the street is the Monroe County Sheriff’s Department, its front doors and windows tinted opaque black. 

On the other is the county jail, a low-slung red brick and corrugated metal building ringed in barbed wire. Small groups of people gather near the entrance to wait, or smoke. 

Tennessee has rolled out a number of programs to prevent NAS, including the VRLAC Jail Initiative. Photo: Jess Mador/100 Days in Appalachia

Teresa Harrill gets out of the car and unloads a stack of file boxes from the backseat. She follows a deputy inside the sheriff’s department building and down a long, dark hallway to a cluttered staff kitchen that doubles as a conference room and education space for inmates at the overcrowded jail. 

Harrill’s been here before. As director of the East Tennessee Monroe County and Loudon County Health Departments, she’s the tip of the spear in Tennessee’s battle against neonatal abstinence syndrome, or NAS, a condition where newborn infants experience withdrawal from opioids their mothers used during pregnancy. 

Rates of NAS are persistently highest in the Eastern third of the state that hugs the Smoky Mountains and the Virginia and Kentucky borders, long hovering above the nation’s, with cases rising ten-fold in the last two decades as the opioid epidemic escalated. 

In 2018, just over 11 percent of every 1,000 live births in Tennessee were babies born with NAS. In the hardest-hit eastern and northeastern counties, rates were at least three times higher.

NAS causes symptoms including seizures, diarrhea, irritability, fever, high-pitched and excessive crying, difficulty breathing, poor sleep and difficulty feeding. Infants could also be at risk for long-term developmental and educational delays. 

To prevent opioid exposure in more babies, Tennessee has rolled out a number of programs to boost access to drug screening and treatment for opioid-affected pregnant women and expand family planning services. That includes outreach programs such as Harrill’s, called the Voluntary Reversible Long Acting Contraceptive, or VRLAC, Jail Initiative. 

The program sends Harrill and a team of nurses and outreach workers to jails scattered around 15 rural East Tennessee counties at least once every other month with the goal of educating incarcerated women about the risks of NAS to infants. The program saw more than 7,800 inmates between 2014 and 2018.

Teresa Harrill holds her NAS prevention trainings every other month for incarcerated women in East Tennessee. Photo: Jess Mador/100 Days in Appalachia

“We started this program for one reason: because we saw so many babies being born that were drug-dependent,” she said. “And our local hospital, Knoxville Tennessee Children’s Hospital, was seeing so many babies in their Neonatal Intensive Care Unit that were born drug-dependent. And the region got together and felt like this was one way that we could possibly help with the situation and maybe reduce those numbers of babies being born” Harrill said.  

Listen as Teresa harrill discusses the vrlac-nas program

Harrill cites inmate survey data presented in 2018 by faculty from the University of Tennessee Public Health and Nursing schools that finds women serving time in jails face a high risk of giving birth to a baby with NAS. Almost all of the women who’ve participated in similar jail programs have a history of drug use, most often with opiates, the study reports, and more than one-third had used drugs during a pregnancy.

Many of the inmates who participate in the health department program have already lost at least one child, Harrill said, an observation backed up by the same survey, which also reports 24 percent of women had a child in state custody. 

“And that’s what’s sad,” Harrill said. “We see a lot of women that already have children, that either their child is in state custody or, you know, grandparents or family members are raising their children while they’re incarcerated.”

Losing children is a familiar experience for many of the Monroe County Jail inmates in attendance at Harrill’s presentation inside the Sheriff’s Department kitchen. 

Half a dozen women in black and white or orange jumpsuits and rubber sandals with socks sit attentively around a conference table as Harrill clicks through her presentation about NAS.  

“The first thing I want to say is, this program, we’re not here to judge,” she told them.

The female inmates in Monroe County gather around a conference room table for Harrill’s presentation. Photo: Jess Mador/100 Days in Appalachia

When Harrill asks if they’re familiar with the term NAS, all of the inmates nod their heads. Many volunteer that they’ve heard the signature high-pitched cry of drug-exposed babies. And several women raise their hands to share personal stories about their own experiences giving birth to babies in opioid withdrawal. 

“I was on pain pills. I was an I.V. user and she was born addicted. I spent the first four years of her life in the penitentiary. What kind of life is that for her?” an inmate named Chrissy told the group. “I think it’s very selfish to bring children into this world and you’re in full-blown addiction. I just think it’s the most selfish thing in the world because there’s so many kids without parents. So, that’s why I got my tubes tied.”

While Harrill isn’t advocating for or against such procedures, she does present options to the women who attend her programs for long-term birth control options. 

As she asks whether any of the inmates are interested in hearing about free, long-acting contraception, explaining the different types, images of IUDs and other forms of birth control appear on the projector screen. 

All of the women at the table raise their hands. They break into small groups to privately discuss their health needs with a health department nurse.  

“It’s up to you. That’s your decision. It’s your decision, not mine not anybody’s, it’s yours. If you’re interested, we’ll be able to bring you to the Health Department,” Harrill said.  

Officials would transport any of the women inmates who request to receive a birth control method to a health department clinic at a later date. 

After about an hour, the NAS-prevention workshop wraps up and Harrill heads out to her car. Piling her boxes back into the backseat, Harrill said it’s critical to educate incarcerated women about the dangers of NAS before they’re released, and before they’re at risk of an unintended pregnancy that could expose a fetus to opioids.

“We looked at them as a population, obviously we would have their attention and obviously that we could get to. ” 
Tennessee Department of Health officials credit state NAS prevention programs with contributing to an overall decline in NAS rates last year, the first such decline since the state began tracking the condition in 2013. 

Promoting the option of long-acting, reversible contraception to prevent unplanned pregnancies among women affected by opioids is in line with the 2017 American College of Obstetricians and Gynecologists Committee Opinion on opioid use and opioid use disorder in pregnancy, which cites research findings that, “unintended pregnancy rates among women with substance use disorders are approximately 80 percent, considerably higher than in the general population. Use of reliable contraception is also lower among this group of women when compared with a nondrug-using comparison population.”

Albert Medina, the jail administrator for the Monroe County Sheriff’s Department, leads inmates from the jail to the NAS prevention workshop. Photo: Jess Mador/100 Days in Appalachia

Maternal-fetal Medicine Physician Dr. Craig Towers sees hundreds of women with opioid addiction at his Knoxville High Risk Obstetrical Consultants practice that also specializes in treating drug-exposed babies. Most of his patients, he said, have had more than one baby and roughly half have had two or more. Towers said an overwhelming number of his patients ask to discuss birth control options during their prenatal and postnatal care visits. 

“A lot of them have had previous babies with NAS. They’ll also tell us we are the first ones that ever talked to them about whether they wanted long-acting reversible contraception and so 100 percent of the women that come to our program, we talk about birth control, all their various options and we make a plan so that as soon as they deliver [their baby] that plan is instituted,” he said, “before they leave the hospital.”

Still, some health advocates question Tennessee’s long-acting reversible contraception program targeting incarcerated women.  

Lesly-Marie Buer is the research director at the Choice Health Network clinic in Knoxville, which provides primary care, mental health, substance abuse and addiction, contraception and other services. She previously worked for the Tennessee Department of Health in an unrelated role. 

Buer said the long-term effects of NAS may prove to be “overblown” in a way that hearkens back to the crack epidemic of the 1980s and early 1990s, when stigma surrounding so-called crack babies sparked widespread alarm about the health effects of drug use during pregnancy on unborn babies. While some initial research, including a study from Dr. Towers, shows children exposed to opioids in utero could face long-term effects, Buer said the research is still ongoing.

Still, she believes more Tennessee residents need access to basic health care, sexual health education and contraception in the abstinence-only state, where schools are barred from talking about even condoms.

“People are not taught about sexual or reproductive health in a meaningful way from the beginning. And so we know that there is a lot of either lack of education or miseducation,” she said. “What’s important for us is that the whole range of contraceptives are offered to everyone and that there is meaningful education around those contraception choices as well as what their efficacy is and what the side effects are, which I think is really important, especially that people know that if they do get a long-acting reversible contraceptive, that they know where to get it taken out, because that’s a huge issue as well–– having transportation or access to actually go get something taken out if you are to have that.”

The Monroe County Health Department’s contraception program often serves a much broader public-health role in rural East Tennessee communities, said Harrill, who lives just a few miles from the Monroe County Jail. She said the department is working on expanding NAS-prevention programs into probation programs for both men and women. 

She acknowledges the reality that many opioid-affected women across the landscape of rolling hills and mountain views, horse farms, Family Dollar discount stores and churches outside Knoxville struggle to access basic health services, mental health care or drug treatment, or prenatal care services during pregnancy.   

“If someone needs something to that degree, they have to go to Knoxville, which is an hour drive, but for the folks here that have no transportation, that it’s an issue, she said. “One of the things that we tried desperately hard to do with the health department is, when we have a patient in for a service we want to make sure we do everything we possibly can for that patient because chances are they might not have a ride next time.”

And, Harrill said, most of the inmates she visits at county jails end up coming home to the community. She hopes the NAS-prevention education they receive behind bars could also empower them to take charge of their overall reproductive health after incarceration. 

She stresses to the inmates it’s up to them whether to accept a contraceptive method. Sometimes, only a handful of women express interest in following up for birth control at the health department clinic afterwards, Harrill said.

“But that’s OK because if we can just prevent one pregnancy of a baby that’s born drug-dependent, then it’s been a success.”

This story is part of the series Born Exposed, exploring access to medical and rehabilitative care in Appalachia for opioid-affected women and their babies. Born Exposed is a project of 100 Days in Appalachia, West Virginia Public Broadcasting and the Ohio Valley ReSource.

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