When Jessica Sanchez tested positive last year for heroin, her probation officer sent her to an Arizona detox center for treatment. But before Sanchez could be admitted, she needed to take a pregnancy test.
That’s how Sanchez, 25, discovered she was expecting her first child. She was four and-a-half months pregnant and had been abusing heroin for four years, following two years of opioid pain pill abuse.
The surprise pregnancy gave Sanchez a deep desire to get clean.
“I had a reason to live,” she said. “[Before], I didn’t feel like life was worth living because I had no reason to get clean.”
But she would soon learn the challenges pregnant women face when they seek drug treatment. The detox center, for example, turned her away, since its cold-turkey approach would put the baby’s life at risk.
Sanchez is just one of thousands of Arizona women who have in recent years become pregnant while still using drugs, often prescription opioids or heroin – just a small piece of a nationwide opioid epidemic. A Centers for Disease Control and Prevention study of 28 states found that babies born with an opioid dependency tripled in the 15 years ending in 2013. Those babies often face severe health consequences.
The epidemic can hit particularly hard in parts of the country where drugs are easy to come by and access to healthcare is limited, such as Sanchez’s hometown of Oracle (population: 3,686), in the foothills of the Santa Catalina Mountains about an hour north of Tucson.
“It was easier to get another fix than to get help,” Sanchez said.
Sanchez would endure two hospital referrals and two stints in jail before eventually landing at Sally’s Place, a 10-bed residential treatment facility in Phoenix where she is now caring for her son, Benjamin, who was born in late January. Sally’s Place is a rarity among treatment facilities. It takes in only pregnant women suffering from substance abuse and mental health disorders and provides them drug abuse recovery services, while teaching them parenting skills.
Sanchez is grateful to have been placed at the facility, operated by the National Council on Alcohol and Drug Dependence (NCADD), but marvels at the labyrinthine path that brought her there. Even the trespassing charge that first led to her probation felt like happenstance.
“It’s crazy,” she said. “I’m mad that that happened, but [if it were not for] me testing dirty and the probation officer not doing what he did … Everything happens for a reason.”
Sanchez has now been off heroin for more than seven months and was recently planning to begin tapering her doses of methadone – a narcotic that is the standard-of-care treatment for pregnant women who are being weaned off other opioid drugs including heroin.
While some women such as Sanchez seek treatment and demonstrate to Arizona’s Department of Child Safety (DCS) their ability to care for a child, many other women go without treatment and some are deemed unfit parents, leading the department in certain cases to place children in foster care.
The impact of Arizona’s opioid epidemic on families and the child welfare system has yet to be calculated. Even so, child welfare professionals say opioid drugs clearly pose a unique threat to children, especially newborns.
‘At Epidemic Proportions’
Every year, hundreds of babies in Arizona are born exposed to opioids.
The number of Arizona babies born exposed to narcotics – a category of drugs referring to opioids – nearly doubled from 234 in 2008 to 462 in 2015, according to state data. Neonatal Abstinence Syndrome, or NAS, which occurs when newborns experience significant withdrawal symptoms after being exposed to drugs in utero, increased 224 percent during that time, from 145 cases in 2008 to 470 cases in 2015.
“I’ve been witnessing first-hand the rise of opioid-exposed babies,” said Kathy Davis, a neonatal nurse with 33 years of experience who volunteers at Sally’s Place. “Hospitals can’t afford beds for these babies. It’s at epidemic proportions.”
Withdrawals can arise from exposure to non-opioid drugs including alcohol and prescription drugs such as Xanax, too. But the withdrawal symptoms connected to opioid exposure are particularly severe, said Susan Smith, prevention administrator at DCS. Those symptoms often begin within 48-72 hours of birth and can include trembling, excessive crying and seizures. In utero exposure to methadone often also triggers NAS.
“Opiates was the game-changer in NAS,” Smith said. “Babies that are born with exposure to other substances don’t have as-significant withdrawal symptoms.”
The disease is still not completely understood. Sanchez’s baby, for example, did not suffer from NAS even as another woman at Sally’s Place who was on a lower dose of methadone than Sanchez gave birth to a baby with the ailment.
“Jessica’s baby had all the strikes against it,” Davis said. “She was a perfect setup and he had none. She is a really good nurturer, she is a very good mother and she bonds very well. Studies show that environment does play a part.”
Babies born with NAS are treated in the neonatal intensive care unit where they are monitored closely and sometimes weaned off their dependency with small doses of morphine. The average length of a hospital stay in the U.S. for babies with NAS is 23 days, at an average cost of $93,400 per infant, according to the CDC. Nationally, and in Arizona, Medicaid is the most common payer.
Witnessing the suffering of a withdrawing newborn can take an especially tough emotional toll on mothers. What’s more, a newborn’s stay in the neonatal intensive care unit also disrupts a crucial maternal bonding period.
“It was extremely hard,” said Kyla, a women recovering from a heroin addiction at Sally’s Place who asked to be identified only by her first name. “A lot of it was guilt and shame brought upon me seeing [my baby] withdrawing and shaking. It was very, very difficult for me – very eye opening, that this is because of my addiction.”
Health care professionals in Arizona are required to alert DCS if they suspect a baby was born exposed to drugs, prompting child welfare to open an investigation. Still, many cases likely go unreported, Smith said.
“Not every mother is asked, ‘Did you use any substances?’” she said.
Women in a handful of Arizona counties including Maricopa and Yuma who give birth to a baby with NAS can be referred by DCS to a program called Substance Exposed Newborn Safe Environment (SENSE) that provides in-home care. The program, developed in 2006, provides families with as many as five in-home visits a week, along with weekly email checkups between parents and service providers. DCS says it hopes to expand the program statewide in the coming years.
“We don’t remove children based on drug use alone,” Smith said. “Their ability to parent has to be impacted by their drug use … It’s not like, ‘You had a substance-exposed newborn. We’re taking your kid away.’ We would work with them on services and support.”
Even so, DCS removals in Arizona have surged in recent years.
From Sept. 2011 to Sept. 2015, the number of children in Arizona’s foster care system increased 63 percent, from 10,883 to 17,738, according to federal data. That was the largest increase of any state in the country.
While that sharp increase coincides with the opioid epidemic, Richard Wexler, executive director of the National Coalition for Child Protection Reform in Arlington, Va., said the rise of kids in care has far more to do with Arizona’s removal policies, which he has characterized as “take the child and run.”
A watershed moment, Wexler says, came in a 2003 speech by then-Gov. Janet Napolitano in which she was quoted as telling caseworkers to “err on the side of protecting the child, and we’ll sort it out later” – part of a broader push by Napolitano to prioritize child safety over keeping families together. In the previous five years, more than two dozen children had died while their cases were in the hands of Arizona child welfare.
“Arizona foster care has been skyrocketing since January 2003, long before the latest so-called ‘drug plague,’” Wexler said.
From 2003 to 2007, removals rose by 26 percent, according to state data.
The economy tanked soon thereafter, and in 2009, the state’s deep budget cuts hit DCS – then a unit within the Department of Economy Security called Child Protective Services – along with social safety net programs offering child care subsidies and other assistance to needy families.
“We had a significant increase [in removals] starting back during the economic downturn in 2009,” DCS’ Smith said. “Services to families funded by our state have been decreasing. When you look at what supports a family, protective factors come in a lot of different ways.”
The department was operating hundreds of caseworkers short of approved staffing levels, and caseworkers were struggling under extraordinarily heavy caseloads.
“That reduced the time available to spend with families,” Smith said.
In 2013, more than 6,000 reports to the department were found to have wrongly not been investigated, on top of thousands of other backlogged cases. The next year, the department was overhauled and relaunched as a standalone agency.
The state has since begun to restore the department’s funding, and DCS says its backlog of cases dropped from about 16,000 at the start of 2015 to about 4,500 in September. In a welcome sign for watchdogs concerned by the rise of kids in care in recent years, Arizona says the number of new removals by DCS fell 7 percent in the year ending Sept. 2016.
But the impact of the opioid epidemic on the state’s child welfare system is still not well understood, since DCS does not detail in its reports the number of removals in which parental drug use was a contributing factor. Instead, the department lumps reports into four categories: neglect, physical abuse, sexual abuse and emotional abuse.
In the last year Arizona made information on drug use and removals public – the year ended June 2012 – drug or alcohol abuse was found to be a contributing factor to the maltreatment of children in 59 percent of removals. DCS says it plans to begin equipping caseworkers with tablet computers this year so caseworkers can once again begin to report detailed information on parental drug use and other issues from the field, the Arizona Republic reported.
Difficult Path To Recovery
For many young mothers battling addiction, opioid drug abuse begins either with a doctor’s prescription or through a friend with access to pills.
Sanchez began using Percocet after a friend’s mother was prescribed the pills following a car crash. Sanchez thought the powerful pills would alleviate chronic back pain, but instead they paved the way for years of heroin abuse.
Another woman at Sally’s Place, Carissa Denny, began using Percocet after breaking both of her ankles in a car crash. She then turned to Oxycodone, and eventually to heroin. By the time she sought treatment, Denny was homeless and had deeply damaged her relationships with family members.
“I was somewhat of a functioning member of society until I broke my ankles,” Denny said. “My reason for wanting sobriety was wanting to give my daughter a life.”
While the nationwide opioid epidemic has ravaged the lives of men and women in nearly all stages of life, the road to recovery can be especially difficult for pregnant women who require drugs such as methadone in their treatment.
For example, after Sanchez was turned away from the first detox center, she was dropped off at a hospital where she expected to get a quick referral to a facility offering methadone, but was told she would have to wait. She decided instead to run away, and had her grandfather pick her up.
Authorities later found Sanchez and took her to a jail in Pinal County, about halfway between Phoenix and Tucson. From there, she was again sent to a hospital. Again, she ran away.
“They said it could take weeks or months before I could get methadone,” she said. “I said, ‘Are you fucking kidding me? I’m withdrawing right now.’ I was sitting on the bed withdrawing and shivering, so I left.”
The next time Sanchez was arrested, she was taken to a jail that offered methadone treatment in Maricopa County. She stayed in that jail for nearly two months before her release in late October. Sanchez landed in Sally’s Place just days after leaving jail following a referral from her probation officer.
Planning for the Future
As more women seek treatment for opioid addiction, Sally’s Place is hoping to expand.
The facility opened in 2015, a dozen years after the opening of another NCADD facility in Phoenix, Weldon House, which provides treatment and housing for mothers. NCADD also opened a Phoenix emergency housing facility for pregnant women six years ago. The idea behind Sally’s Place was to increase long-term drug treatment services specifically targeted at pregnant women battling addictions.
“We really started it because there’s a population that was not being treated,” said Carol Lagnese, program supervisor at NCADD. “There are very few places they can go to get treatment, where it’s geared towards them keeping their baby. The places they can go are geared towards serious mental illness, not drug treatment.”
As women at Sally’s Place progress through treatment, they are encouraged to plan for an independent future. Sanchez said she hopes to follow her passion for cooking into a career as a baker or chef. Denny is working towards becoming a drug abuse counselor. When women graduate from Sally’s Place, a bed or two may open up at a time, but Lagnese says the demand is outpacing the supply.
“We’d like to have a ‘Sally’s Place 2,’ because the need is there and we feel like this is something that works,” she said.
Meanwhile, an effort is also underway to expand and change NAS care in Arizona.
Davis, the nurse, and others are working to create a specialized NAS facility that improves on the neonatal intensive care unit. While the NICU can irritate withdrawing newborns with its loud noises and bright lights, the proposed facility would provide newborns with dimmer lighting and specialized care.
Perhaps the largest challenge to child welfare and service providers will be to provide care for the untold number of pregnant women and new mothers in Arizona that have either not sought treatment, have turned it away or see treatment as inaccessible.
Sanchez says despite the challenges she faced, she knows treatment was the right decision.
“It’s been really amazing,” she said. “I’m learning to be a clean person and a mom. It’s really good. My baby is with me 24/7.”
Jonathan Polakoff is a writer living in Los Angeles. His work has appeared in the Los Angeles Business Journal, Easy Reader, Argonaut and other publications.