By Alison Knopf
Loretta Finnegan
Loretta Finnegan, MD, a champion of medication-assisted treatment with methadone, developed her scoring system for newborns more than 40 years ago. The Finnegan Neonatal Abstinence Scoring System (FNASS) assigns a numerical score to 21 clinical signs, and babies are treated accordingly. Developing the test was an important step in making sure that these babies were treated with morphine, if necessary, to manage the symptoms of withdrawal.
But the work of Dr. Finnegan goes far beyond the Finnegan score. When she first started an opioid treatment program (OTP) at Thomas Jefferson University in Philadelphia, 44 years ago, Dr. Finnegan opened a landmark program for pregnant women addicted to opioids. Since then, the program, called Maternal Addiction Treatment Education & Research (MATER), has included intensive outpatient treatment as well as residential treatment.
Diane Abatemarco
Diane Abatemarco, PhD, MSW, director of MATER and associate professor of OB/GYN and Pediatrics at the Sidney Kimmel Medical College at Jefferson, talked with AT Forum about the scope and importance of Dr. Finnegan’s work.
Precipitating Factors
Poverty and childhood trauma are the precipitating factors for almost all women who enter the MATER program, said Dr. Abatemarco. They are also the factors that make it difficult for the women to stay in recovery, she added.
What the MATER program offers is not only the medication—methadone or buprenorphine—and therapy needed to maintain recovery, but the wraparound services, which go farther than those of a typical OTP. Women attend seven days a week and spend at least 10 hours and 30 minutes weekly in group and individual substance use treatment. Their prenatal care is managed at Jefferson. “The fact that Loretta created an OTP here was just remarkable at that time, and housing it in a medical university, offering access to all the other kinds of care that women would need, shows her wisdom and vision,” Dr. Abatemarco said.
NAS Babies Grow Up to Become Normal
We first met Dr. Finnegan in Chicago, many years ago, when she and Ira Chasnoff, MD, presented a program on babies whose mothers had been addicted to cocaine. That presentation was crucial to helping erase the awful epithet “crack baby,” implying that the babies would be permanently damaged. These babies were, in fact, normal. And the same applies to babies born with neonatal abstinence syndrome (NAS). “Loretta was a key person in saying that while four in 10 babies exposed to opioids may have NAS, they’re going to be normal, healthy children and adults,” said Dr. Abatemarco.
Dr. Finnegan also strongly believes in the importance of the mother to the child. Great trauma ensues when the two are separated, and this separation often has taken place in the name of protecting the child, when in fact, just the opposite results.
“The problem is the deep misogyny in the United States, where corporations don’t have to cover birth control for their employees,” Dr. Finnegan said. Mothers who are faced with child abuse and neglect charges over opioid use disorders—or babies born with transient NAS, which can also be due to therapeutic methadone or buprenorphine—are victims, as well. “With these moms, it’s just an extension of that; they don’t have the rights over their own children.”
Mom Is the Best Medicine
“As a social worker and a researcher, I know that if you take kids away from their biological parent, and they go into the foster care system, the risk of the non-attachment is a lifelong brain injury,” said Dr. Abatemarco. Even in the worst case scenario—a child scoring “severe” on the Finnegan score—the mom can have rooming in and breastfeed her child, and that score drops exponentially, even without medication, she said. Keeping the mother and baby together from the beginning is a key contribution Dr. Finnegan made to the field.
Dr. Finnegan, who herself had five children in her 20s, continues to stress the importance of the mother-child bond.
“I really do feel if we’re going to battle this epidemic and win, we’re going to need comprehensive therapeutic programming everywhere in the country,” said Dr. Abatemarco. “It cannot be, ‘Just give a woman a prescription for methadone or buprenorphine,’ because that won’t solve the problem.”
Treating Mom, Too
In a study Dr. Abatemarco conducted with MATER patients, funded by a federal grant, she found that each patient had an average of four adverse childhood experiences (ACEs). Based on research, having four ACEs already puts an individual at very high risk for a mental illness or a substance use disorder.
That’s why methadone or buprenorphine alone won’t help them enough. “These women need psychotherapy, housing, they need help with the court system and more,” said Dr. Abatemarco, noting that these services are provided by MATER. “We’re going to have to go back to the social safety net, the way it used to be, and rebuild some programs the way Presidents Kennedy and Johnson developed them,” she said. “Programs need the ability to provide wraparound services.”
In addition, Dr. Abatemarco supports teaching mothers about parenting, “so we can stop the intergenerational trauma.” She has been using “mindfulness” training in her research.
How the Program Works
The MATER residential program has 22 beds for mothers, who can each bring up to three children.
The women come as soon as they know they are pregnant, usually finding their way to the program, which of course also has intensive outpatient and regular outpatient services. Usually the women go to the emergency department. If at Jefferson, they are taken right up to the labor and delivery area, and MATER “navigators” meet them at the bedside.
The women stay in the hospital for from a few days to a week for stabilization on either methadone or buprenorphine during their pregnancy. As soon as they are discharged from the hospital, they come to the MATER program, every day. If, when admitted, the mother was already on methadone, she stays on methadone. If she was already on buprenorphine, she can continue, or switch to methadone. “They make the decision with the doctor,” said Dr. Abatemarco.
Typically, the program used methadone in the past. “That was getting the women to come here 7 days a week,” said Dr. Abatemarco. “And, because we had them coming anyway, we could gently wrap the services around them.” Now, MATER is doing the same thing with buprenorphine, requiring patients to come in every day (the combination product, with naloxone, is not recommended for during pregnancy). As for Vivitrol, Dr. Abatemarco says it should not be used during pregnancy.
Open House
After Dr. Finnegan’s retirement from MATER, the next director was Karol Kaltenbach, PhD, followed by Dr. Abatemarco, who convinced Jefferson to buy a residential treatment facility for the program. Recently an open house reception was held for the opening, and Dr. Finnegan was present.
In addition to attending the open house, Dr. Finnegan was present when First Lady Melania Trump visited the program in November, and when President Trump signed the new opioid law this fall. She also attends every AATOD meeting. At last spring’s meeting, she spoke loudly and clearly about the challenges to OTPs and patients. Her awards are many, and keep coming.
For a 2015 news article based on an interview with Dr. Finnegan, go to http://www2.philly.com/philly/health/20151210_Helping_babies_born_to_addicted_moms.html