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鈥檛 find a doctor nearby who will prescribe the addiction medicine they need to keep them healthy during pregnancy 鈥� 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.
鈥淎s long as it鈥檚 taken the way it鈥檚 supposed to be taken and treated the way it鈥檚 supposed to be treated it鈥檚 an amazing thing,鈥� 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. 鈥淚鈥檝e never went through so much hassle to get something that I need, that my doctor agrees that I need,鈥� 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鈥檚 and baby鈥檚 lives are at stake, some doctors even drop their patients. It鈥檚 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.
鈥淓veryone 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,鈥� 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: 鈥淗e said, if we find out you鈥檙e pregnant and you haven鈥檛 told us you're pregnant already we have to discharge you.鈥�
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, 鈥淵ou鈥檙e going to have to find a new doctor.鈥�
When a women in Linnemeier鈥檚 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鈥檚 in her final trimester and starts using street drugs again, there鈥檚 also a risk of miscarriage.
It鈥檚 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.
鈥淲hat happened was we started getting patients coming into us saying 鈥業 was on Subutex and my doctor cut me off and I don鈥檛 know what to do,鈥欌�� 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鈥檛 just stop prescribing once a patient gets pregnant.
鈥淚f I had my way, whatever doctors were taking care of them before, would continue to take care of them,鈥� she says. 鈥淪topping it is the worst thing you can do.鈥滱t 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 .
In fact, firing pregnant patients is not only risky, it鈥檚 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鈥檛 need to be an obstetrician to prescribe buprenorphine to pregnant women. Any doctor with the DEA waiver can prescribe for these women.
鈥淎 lot of physicians become fearful in that situation because they鈥檙e not fully educated, or they don鈥檛 understand how these patients should be managed,鈥� Baxter says.
Baxter says, as long as their patient has an OB-GYN that鈥檚 aware they鈥檙e taking Subutex, the primary care physician can keep prescribing. 鈥淭he fear that some prescribers have is really unfounded,鈥� he says. 鈥淭here鈥檚 very little risk.鈥�
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鈥檚 clinic in Indianapolis. The first fired her. The second refused to treat her. The third didn鈥檛 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.
鈥淭hank God I had enough to last me,鈥� she says. 鈥淎t least I wasn鈥檛 withdrawing.鈥�
But Linnemeier is happy she landed where she did. 鈥淭he nurses and the doctors are amazing,鈥� she say. 鈥淚 love it.鈥�
She says she鈥檇 hate for other women to go through the uncertainty she went she went through. She鈥檚 just thankful she and baby made it to a new doctor.
鈥淚 got to hear a heartbeat today so I know she鈥檚 OK,鈥� she says. 鈥淎nd I got to see her a few days ago and everything is fine.鈥�
This story was produced by, a news collaborative covering public health.
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