Tennessee Doctor Bucks Conventional Medical Wisdom for Pregnant Addicts

When Dr. Craig Towers first started seeing opioid-addicted pregnant women in his high-risk OB-GYN practice, he followed the longstanding recommendations of national medical groups.

"For 28 years, I did what I was taught - that you don't detox during pregnancy because it's dangerous," said Towers, a professor of obstetrics and gynecology at the University of Tennessee in Knoxville, where he operates his practice.

After treating increasing numbers of opioid-addicted patients in recent years, Towers has decided to buck conventional medical wisdom and take a controversial approach that now puts him at odds with the nation's leading medication associations.

Guidelines from the American Society of Addiction Medicine and the American College of Obstetrics and Gynecology, strongly advise against a cold turkey approach to pregnant addicts. Detoxing from opioids causes severe maternal and fetal stress, including high blood pressure, vomiting, nausea and severe 'flu like symptoms in mothers. It's also associated with an increased risk for relapse among mothers.

Instead, both national groups and the majority of physicians adhere to the gold standard for treating opioid addiction in the United States: providing all opioid addicts - pregnant women included - with replacement medications that quell cravings without a mind-altering high that has shown to be highly effective in preventing relapse.

Towers' patients are instead weaned off opioids with the goal for the mother to be drug free by delivery. He also requires them to attend behavioral therapy.

"While I understand the motivation for people like Dr. Towers, detox is incredibly unrealistic," said Dr. Mishka Terplan, a professor of obstetrics, gynecology and psychiatry at Virginia Commonwealth University. As a member of the American College of Obstetricians and Gynecology's work group on opioid addiction, he help craft their guidelines.

Terplan said he is alarmed by an approach that is antithetical to proven medical practice in addiction treatment.

Replacement therapy accompanied by behavioral therapy and support have been the most effective way to treat opioid addiction, he said.

"Why would we treat the illness of addiction different in pregnancy than in non-pregnancy," he said. "Why would we provide inferior treatment to pregnant women?"

Towers, however, remains convinced his approach will soon prove to have a track record that national medical groups will not be able to ignore - or dispute.

And he said he cannot understand why opioids are treated so differently from alcohol or cigarette addiction when it come to pregnant moms.

"The goal is to get them off alcohol," he said. "The goal is to get them off cigarettes. Why do we take such a different approach to opioids?"

While treating addicted expectant mothers with opioid replacement drugs stabilize the women during pregnancy, they also negatively affect the fetus.

Some 65 percent of women receiving medication assisted treatment gave birth to babies with symptoms of neonatal abstinence syndrome (NAS) - a diagnosis that covers shakes, jerks and inconsolable crying from newborns who ingested the drugs in utero.

Of the 341 NAS babies born in Tennessee thus far this year, 222 suffered health issues as a result of the medication-assisted treatment for their mothers - a number that is on the same pace as previous years, according to data compiled by the Department of Health.

Opioid use overtakes tobacco

"For my patients, the first thing out of their mouth is that I didn't intend to get pregnant," Towers said. "The second thing is I want to be off these drugs so my baby doesn't suffer."

No patient is coerced into detoxing and about a third of his patients choose replacement therapies, he said.

"The only thing I do differently than the (American College of Obstetrics and Gynecology) is that I offer it," he said. "If you want to detox, I will help you. They're talking about it's bad because they might relapse, and I'm saying it's bad if we don't try."

Tennessee health officials have taken notice of Tower's approach.

Timeline: How the opioids crisis took hold

Dr. Stephen Loyd, medical director for the Division of Substance Abuse Services, said state officials are examining a pilot project to offer women the choice to detox - while official state policy for TennCare patients remains providing pregnant women with medication alternatives.

Lloyd said that the issue comes down to a women's choice and patient autonomy.

"A lot of women are highly motivated to detox while pregnant," he said. "They realize there is something bigger than themselves. Nobody is forcing women to do anything, but why should they have the choice?"

Towers' approach has also gained the attention of judges on a state-wide opioid task force, who sent a letter to Tennessee legislators calling Tower's approach an innovative option that should be part of a broader policy discussion.

At least one east Tennessee judge has relied on Towers' approach to send pregnant women who come through his court and test positive for illegal opioids to jail to detox.

“The goal is to stop babies being born who suffer so greatly," said Judge Duane Slone, who oversees drug courts in northeast Tennessee heads a judicial task force focused on opioid abuse.

Like Towers, Slone's approach puts him at odds with his field's national professional organization.

Terrence Walton, a longtime addiction treatment specialist with the National Association of Drug Court judges, said his group strongly discourage any practice that would require a cold-turkey relapse in jail rather than a medically recommended treatment program.

"The urgency when judges are confronted with pregnant women, I get that," Walton said. But the focus has got to be getting mother treatment she needs to both avoid illicit opioid use and avoid withdrawal."

Reach Anita Wadhwani at awadhwani@tennessean.com; 615-259-8092 or on Twitter @AnitaWadhwani.

How a Tennessee OB-GYN turned into an addiction specialist for pregnant women

http://www.tennessean.com/story/news/2017/06/02/tennessee-doctor-bucks-conventional-medical-wisdom-pregnant-addicts/346365001/