Zachary Siegel, Independent Journalist (@ZachWritesStuff)
Eleven years ago, something snapped inside Dr. Candy Stockton.
She was a busy family medicine physician treating middle class, well-insured patients in Southern California, but she felt unfulfilled. Then a patient who was dissatisfied with his relationships, his job, and his whole life committed suicide.
"I remember thinking his story wasn't that different than mine," Stockton said. "I couldn't imagine killing myself, but it was really a wake-up call."
Dr. Candy Stockton successfully treats pregnant women with opioid addiction in rural Shingletown, near Redding. Photo by Hung Vu.
So she and her family made a big change. With her husband and two young children, Stockton packed up and moved hundreds of miles north to rural Shasta County. Today, Stockton, 42, practices family medicine at the Shingletown Medical Center in a tiny town in the shadow of Mt. Lassen, 30 miles east of Redding.
The majority of Stockton's patients live in poverty. "The economy is terrible," she said, adding that the lack of educational opportunities for kids creates a cycle of despair that can afflict families for generations. With that despair has come alcoholism and a dramatic increase in addiction to opioids. But what really moved Stockton was the pregnant women she saw who were struggling with opioid addiction, threatening their own health and that of their developing babies.
Stockton saw the chance to make a big difference: Treating pregnant women with opioid addiction would help both mother and baby, two generations at once. When she starts caring for these patients, she likes to start with the same icebreaker: "This is a judgment-free zone," she tells them.
"A lot of these women who are pregnant and addicted have been treated poorly by the medical community," Stockton said, adding that these negative experiences reinforce barriers to receiving addiction treatment, a precious resource lacking for pregnant women living in rural Northern California.
To earn their trust, Stockton and her staff offer something these women don't get enough of: encouragement. "They're not bad people — they have a drug problem, and they really want their baby to be okay," she said. "I tell them addiction is a chronic disease that's no different from other problems we treat."
So long as these pregnant women stick with the treatment and show up when they need to, Stockton tells them their babies will be healthy.
Stockton's talent and expertise is needed more and more. A recent JAMA Pediatrics study found a sharp increase in babies born dependent on opioids — and, mirroring the opioid epidemic as a whole, it's worse in rural areas. From 2004 to 2013, the proportion of infants born dependent on drugs — mainly opioids — increased nearly sevenfold in rural counties, nearly double the increase in urban areas.
Stockton, a primary care physician, didn't go into medicine thinking she'd treat patients who are both pregnant and opioid addicted. But practicing rural health care on the front lines of an emerging public health crisis prompted her to learn. Where many physicians are reluctant to treat this more challenging group, Stockton saw the gap and embraced it.
Using Buprenorphine to Stop Human Suffering
"I think it's important that we step up and try stuff we're not comfortable with," Stockton said. "I have always wanted to fix things, to make things better. I've never liked to watch human suffering of any kind."
By stabilizing a pregnant woman with opioid addiction, in effect stabilizing the baby, Stockton is giving families a second chance and breaking a family's cycle of sorrow. She has treated seven pregnant women with substance problems over the last year, but roughly 50 newborns a year in Shasta County are opioid dependent. There are no addiction specialists or treatment centers nearby, and women have nowhere else to go. Stockton is helping to train and mentor other primary care providers so more women can get the help they need to deliver healthy babies.
To provide better care to patients with opioid addiction, Stockton completed an eight-hour course to become licensed to prescribe buprenorphine, a tightly regulated drug that works by activating opioid receptors just enough to quiet down cravings for opioids. People taking buprenorphine say they feel normal for the first time since they started using opioids. They can hold down jobs, parent their children, and live productive lives. For pregnant women with opioid addiction, it's the safest known way to ensure the baby is healthy.
That's why Stockton began attracting patients like Shelby, a 30-year-old woman pregnant with her second child and struggling with opioid addiction. Shelby, who asked that we not use her last name, was prescribed opioids for pain after giving birth to her first child more than a decade ago. Eventually, she began misusing the pills to cope with the loneliness and isolation she felt with her fiancé constantly working to support the family. "I was by myself all the time," she said. "I started to lean more on opioids for energy and as a security blanket."
A near-fatal overdose prompted her to seek treatment. She started out at the closest methadone clinic, but that was a three-hour roundtrip drive, and methadone treatment requires daily visits. She eventually found one of the few doctors in her area licensed to prescribe buprenorphine.
Searching for a Doctor
Shortly after she made the switch, Shelby found out she was pregnant. "I was terrified," she said. "My firstborn just turned 9 years old, and I had never been pregnant while on a drug before." Worse, Shelby's doctor was unfamiliar with treating pregnant women with buprenorphine, so Shelby struggled to find a new physician who could.
The next doctor Shelby saw was "extremely rude," she said. "She told me if the baby came back positive for opiates or is in withdrawal that I'd have a huge situation on my hands — that my baby would be taken away by Child Protective Services."
Finally, Shelby found Stockton — and treatment that was compassionate and motivating.
"It was a night-and-day difference," Shelby said. "She gave me pride. She would tell me to look at where I am now, to look how far I've come."
If a woman continues to use opioids like oxycodone or heroin while pregnant, there's a high risk the newborn will experience neonatal abstinence syndrome, also known as drug withdrawal. Symptoms range from tremors and high-pitched crying to seizures, which can persist for days or months. Quitting opioids in the middle of pregnancy can cause a miscarriage or premature birth, and experts recommend continuing buprenorphine treatment throughout pregnancy. While infants born to women on buprenorphine may need temporary treatment to prevent withdrawal symptoms, the mothers and babies are much healthier than the alternative — untreated addiction.
Shelby followed Stockton's treatment plan and had a smooth pregnancy. "She was amazing at guiding me," Shelby said. "Dr. Stockton always said, 'You're doing good; you're doing what you need you to do.'"
Shelby's daughter, Leiah, now 15 months old, was born "with nothing in her system," Shelby said. "A perfectly healthy baby."
Shortage of Clinicians Licensed to Prescribe
Despite years of research proving medications like methadone or buprenorphine are the best ways to treat opioid addiction, especially for pregnant women, policy barriers prevent easy access to these drugs. There's a shortage of providers licensed to prescribe these medications. Even after getting licensed, there's a cap on the number of patients a physician can treat — 30 in the first year and up to 275 after that.
Clinicians are not required to jump through the same bureaucratic hoops to prescribe a medication for any other condition.
The Shasta public health department says 2,400 residents need addiction treatment. "We only have capacity to treat 260 patients with buprenorphine," Stockton said. If more doctors got the buprenorphine license, literally hundreds more patients could access treatment. "If we can go from treating 200 to 400 to 800 patients — that would be huge."
The clinic in Shingletown, California, near Mt. Lassen, where Dr. Candy Stockton practices family medicine.
"I get calls from people every week that we don't have the capacity to take," Stockton said. That's why more doctors need to step up and get their buprenorphine licenses, she said.
Leading the Way
Stockton was selected as a CHCF Leadership Fellow in 2015, and her fellowship project has been working with other area doctors to persuade more physicians to obtain a license to prescribe buprenorphine. She has held seminars and educational sessions on addiction treatment and offered individual mentoring to physicians to help them navigate challenges and integrate the service into their general practice.
The success of mothers and babies like Shelby and Leiah are powerful stories and may help encourage physicians to become prescribers, and patients to engage in treatment.
Stockton recently asked Shelby to talk to another patient — a woman pregnant for the first time, struggling with opioid addiction and very frightened.
"I brought my little girl in," Shelby recalled, "and showed this mom, who was so nervous and terrified, how healthy my baby was. I told her everything was fine. That I was okay."
Stockton said the woman broke down crying.
"Shelby's baby is beautiful," Stockton recalls the woman saying. "It was magic for her to see a healthy baby, to believe that things would be okay."
Clinicians can learn about the role of buprenorphine in addiction treatment and become licensed prescribers. SAMHSA compiles training resources for physicians and for nurse practitioners and physician assistants.
Zachary Siegel is a Los Angeles-based journalist specializing in reporting on science and health. He frequently contributes to The Daily Beast and The Fix, and his work has also appeared in Salon, Huffington Post, and Slate. He writes often about addiction, sometimes drawing on his own experience. Five years ago he was successfully treated for an addiction to heroin.