SC woman gets 20 years in breastfeeding overdose

[Velar Fricative]

Oh my.

www.washingtonpost.com/national/sc-woman-faces-sentence-in-breast-feeding-overdose/2014/04/04/eed46b26-bbeb-11e3-80de-2ff8801f27af_story.html?tid=pm_pop

SPARTANBURG, S.C. — A judge sentenced a South Carolina woman to 20 years in prison Friday for killing her 6-week-old daughter with what prosecutors say was an overdose of morphine delivered through her breast milk.



A prosecutor said Stephanie Greene, 39, was a nurse and knew the dangers of taking painkillers while pregnant and breast feeding, instead choosing to conceal her pregnancy from doctors so she could keep getting her prescriptions. She lost her nursing license in 2004 for trying to get drugs illegally.



Greene’s lawyer said she was only trying to stop debilitating pain from a car crash more than a decade before and relied on her own judgment and medical research on the Internet instead of the advice of doctors and is still overwhelmed with grief from the loss of her child.



The 20-year sentence was the minimum after a Spartanburg County jury found Greene guilty of homicide by child abuse Friday. She could have faced up to life behind bars. Greene will have to serve 16 years before she is eligible for parole. She said nothing in court and quietly shuffled out of the courtroom, her hands and feet shackled, after she was sentenced.



Her lawyer said she will appeal and it’s likely the case will be tied up for years to come. Both the prosecutor and Greene’s lawyer agree no mother has ever been prosecuted in the United States for killing her child through a substance transmitted in breast milk. Also, prosecutors didn’t prove how the baby got the morphine and there is little scientific evidence that enough morphine can gather in breast milk to kill an infant, Greene’s lawyer Rauch Wise said.



“The court can’t punish her any more than she already has been by losing a child,” Wise said.



Greene’s husband did not talk to reporters. Wise said he supported his wife and was devastated as he prepared to raise their 7-year-old son alone.



Greene’s fourth pregnancy in 2010 was unplanned, but she and her husband of 10 years joyously accepted the surprise, her lawyer Rauch Wise said. She has two children from a previous marriage.



Alexis was born healthy, and her mother chose to breast feed. Forty-six days later, Greene called 911 to report her baby was unconscious in her bed. On a recording of the call, she sounds groggy and unfocused. The former nurse first tries to do CPR compressions on the baby’s back and has trouble counting to keep pace. Investigators at the scene found dozens of pill bottles and painkiller patches on her nightstand where the couple’s then 4-year-old son could get to them.



A toxicology report from the baby’s autopsy found a level of morphine in the child’s body that a pathologist testified could have been lethal for an adult, prosecutor Barry Barnette said.



A review of her medical records showed Greene carefully hid her pregnancy from her primary doctor. After a home pregnancy test showed she was pregnant, she told her doctor she needed to go to a gynecologist for a birth control. She then got prenatal care from that doctor while not telling her all the painkillers she was taking, Barnette said.



“She was a nurse. She knew how to work the system,” Barnette said. “She caused the loss of that child.”



But that is an unfair characterization of a woman who remains racked with chronic pain from a 1998 wreck where she fractured her skull and pelvis, Wise said.



“She needed those meds to get up in the morning and function,” Wise said. “She was on total disability because of her pain, her fibromyalgia and all the other things wrong with her.”



Greene still faces 38 counts of obtaining prescription drugs through fraud, and Barnette said he is still deciding whether to take those cases to court



Greene had her nursing license suspended in South Carolina in 2004 because she was irrational at work, tried to call in a prescription illegally and refused a drug test, according to an order from the state’s Nursing Board.



Barnette doesn’t want his prosecution to stop women from breastfeeding. He took this case personally because his wife had a miscarriage in 1989. She is a nurse and personally reviewed the case.



“We make sacrifices every day for our children,” Barnette said. “She decided she was going to have her drugs and sacrifice the health, and ultimately the life, of her child.”

[karinothing]

Very interesting. She has to be on a pretty large amount of morphine in order for it impact the baby right? I mean folks get narcotics after c-sections and they breastfeed. While I hear it can impact the baby, babies are certainly not dying en masse from this.

I know it mentions she had pain patches laying around, I wonder if the baby accidentally got a pain patch or something. Ugh, so horrible.

And I agree with barnette. I don't care if she was in pain, she was using the system improperly and her baby died because of improper behavior.

[iammalcolmx]

My lord.

[quickstepstar]

I think it is interesting that they said that the baby had enough morphine in her system to kill an adult. I wonder if that's the case, how come the baby could have gotten it all from breast milk? Wouldn't the mother than have even higher levels? And if so, how did she survive that?

[debatethis]

Apr 4, 2014 13:42:24 GMT -5 karinothing said:

Very interesting. She has to be on a pretty large amount of morphine in order for it impact the baby right? I mean folks get narcotics after c-sections and they breastfeed. While I hear it can impact the baby, babies are certainly not dying en masse from this.

I know it mentions she had pain patches laying around, I wonder if the baby accidentally got a pain patch or something. Ugh, so horrible.

And I agree with barnette. I don't care if she was in pain, she was using the system improperly and her baby died because of improper behavior.

To the bolded, LactMed says this: Maternal use of oral narcotics during breastfeeding can cause infant drowsiness, central nervous system depression and even death. Newborn infants seem to be particularly sensitive to the effects of even small dosages of narcotic analgesics. Once the mother's milk comes in, it is best to provide pain control with a nonnarcotic analgesic and limit maternal intake of morphine to a few days at a low dosage with close infant monitoring. If the baby shows signs of increased sleepiness (more than usual), difficulty breastfeeding, breathing difficulties, or limpness, a physician should be contacted immediately.

This woman clearly wasn't limiting her morphine to a few days at a low dose if the newborn baby had enough in her system to kill an adult.

ETA: The only other thing I could think of was that she was already so strung out that she went to put another pain patch on and it slipped off, she didn't realize it, and it got stuck to the baby in bed.

[origami]

So she was a drug addict, is what I'm guessing.

[karinothing]

Apr 4, 2014 13:51:40 GMT -5 quickstepstar said:

I think it is interesting that they said that the baby had enough morphine in her system to kill an adult. I wonder if that's the case, how come the baby could have gotten it all from breast milk? Wouldn't the mother than have even higher levels? And if so, how did she survive that?

She had built up a tolerance I imagine.

[NewOrleans]

oh, hell.  Another sad story of addiction. 

But this--

Barnette... He took this case personally because his wife had a miscarriage in 1989. She is a nurse and personally reviewed the case.

^o)

[heyjude]

What a horrible story.

[origami]

Apr 4, 2014 13:53:21 GMT -5 karinothing said:

Apr 4, 2014 13:51:40 GMT -5 quickstepstar said:

I think it is interesting that they said that the baby had enough morphine in her system to kill an adult. I wonder if that's the case, how come the baby could have gotten it all from breast milk? Wouldn't the mother than have even higher levels? And if so, how did she survive that?

She had built up a tolerance I imagine.

I'm ASSuming she got hooked on pain meds after the accident and when those became ineffective, graduated to more and more powerful drugs.

[racegrrl714]

Apr 4, 2014 13:52:17 GMT -5 debatethis said:

ETA: The only other thing I could think of was that she was already so strung out that she went to put another pain patch on and it slipped off, she didn't realize it, and it got stuck to the baby in bed.

This is kind of what I was thinking.

[KateAggie]

Yeah, I have no issue with this. She killed her child. Her out of the womb child. You wanna keep taking drugs? Feed formula.

As far as why the prosecuter took it personally, I don't really care. This isn't a fetal death case. This was a living child.

Sent from my SAMSUNG-SGH-I747 using proboards

[cinnamoncox]

What a horrible story
The poor father too.

[Deleted]

Apr 4, 2014 13:54:04 GMT -5 NewOrleans said:

oh, hell.  Another sad story of addiction. 

But this--

Barnette... He took this case personally because his wife had a miscarriage in 1989. She is a nurse and personally reviewed the case.

No shit. Unless his wife is on the payroll at the DA's office, its highly improper for her to be reviewing his case files and for him to be basing his charging decision on her expertise.  And don't get me started on him admitting that he took a case "personally...."

[ttt]

I am suspicious that the baby even received the morphine through the breastmilk. And if it was through any other way, she deserves even more than twenty years.

[earlgreyhot]

Apr 4, 2014 13:54:04 GMT -5 NewOrleans said:

oh, hell.  Another sad story of addiction. 

But this--

Barnette... He took this case personally because his wife had a miscarriage in 1989. She is a nurse and personally reviewed the case.

Yeah, that's some paternalistic BS right there. 

But the outcome is sound, it's just sad no one was able to step in before the baby died. 

[fortmyersbride]

I posted on MMM too, but holy inappropriateness on the part of her PCP. Chronic pain patients should always be seen in person to obtain their next narcotic pain prescription. A family member picking up the Rx is unacceptable. She should have been regularly screened with regular drug testing. And frankly given the fact that she had a history of diverting at work and thus losing her nursing license, this woman would have been better served in a very closely monitored pain clinic or addiction program. I hope the PCP is disciplined by the state medical board and DEA.

A chronic pain patient can develop such a tolerance to opioids over time that the levels in his/her blood could be lethal to an opioid naive person. Whether the levels in the breast milk would be as well is hard to say, but I would have expected the baby to build up some tolerance due to chronic exposure. Regardless, it is sad that she was able to access so many medications such little monitoring and it came to this.

[ColoRxGirl]

Lots of questions here:

As a PP stated, how is she getting highly potent narcotics at high doses without a PCP noticing she was pregnant? Not unheard of, obviously, but does raise an eyebrow.

If she had "patches" of stuff around, she wasn't just on morphine. Sounds like fentanyl transdermal - well beyond normal pain meds for most conditions. Clearly, she was habituated to highly potent agents. And likely on them throughout her pregnancy. How this infant didn't show signs of opiate withdrawal after delivery, and how the mother concealed her narcotic use during her labor and delivery, is surprising - and frightening.

If this patient was visibly pregnant, I'm surprised a curious pharmacist didn't think to call a prescriber to confirm the dosing. I don't work in the outpatient world, but being aware of a patient's pregnancy status is definitely on our radar in the hospital setting - from both a safety and liability standpoint.

And, yes, opiates most definitely do cross into breastmilk. To achieve fatal levels in the infant would have required significant consumption by the mother. Rare, but not unheard of.

[ttt]

Apr 5, 2014 10:40:40 GMT -5 ColoRxGirl said:

Lots of questions here:

As a PP stated, how is she getting highly potent narcotics at high doses without a PCP noticing she was pregnant? Not unheard of, obviously, but does raise an eyebrow.

If she had "patches" of stuff around, she wasn't just on morphine. Sounds like fentanyl transdermal - well beyond normal pain meds for most conditions. Clearly, she was habituated to highly potent agents. And likely on them throughout her pregnancy. How this infant didn't show signs of opiate withdrawal after delivery, and how the mother concealed her narcotic use during her labor and delivery, is surprising - and frightening.

If this patient was visibly pregnant, I'm surprised a curious pharmacist didn't think to call a prescriber to confirm the dosing. I don't work in the outpatient world, but being aware of a patient's pregnancy status is definitely on our radar in the hospital setting - from both a safety and liability standpoint.

And, yes, opiates most definitely do cross into breastmilk. To achieve fatal levels in the infant would have required significant consumption by the mother. Rare, but not unheard of.

Has this happened before???

[DirtySouth]

I give a big WTF to the husband for allowing his drug addict wife to be caring for children.  There is no way he didn't know about her problem.  She lost her nursing license due to drug seeking and being irrational at work.  She was so groggy when she called 911 that she couldn't even count.  She kept dozens of bottles of painkillers laying around.  Shame on him for seeing all of this and not stepping in.

We had a family acquaintance with an addiction this bad.  She actually made a comment about how she didn't mind if the painkillers were in her breastmilk because it would keep the baby calm.  The situation was the same with prescription bottles all over the place, although she never seemed really f-ed up when we saw her.  My mom talked to her husband, who got all angry and defensive.  The woman ended up dying in her 30's because she took so many pills that she vomited and aspirated.  Thankfully it wasn't the baby who died.

[ColoRxGirl]

Apr 5, 2014 13:01:34 GMT -5 ttt said:

Apr 5, 2014 10:40:40 GMT -5 ColoRxGirl said:

Lots of questions here:

As a PP stated, how is she getting highly potent narcotics at high doses without a PCP noticing she was pregnant? Not unheard of, obviously, but does raise an eyebrow.

If she had "patches" of stuff around, she wasn't just on morphine. Sounds like fentanyl transdermal - well beyond normal pain meds for most conditions. Clearly, she was habituated to highly potent agents. And likely on them throughout her pregnancy. How this infant didn't show signs of opiate withdrawal after delivery, and how the mother concealed her narcotic use during her labor and delivery, is surprising - and frightening.

If this patient was visibly pregnant, I'm surprised a curious pharmacist didn't think to call a prescriber to confirm the dosing. I don't work in the outpatient world, but being aware of a patient's pregnancy status is definitely on our radar in the hospital setting - from both a safety and liability standpoint.

And, yes, opiates most definitely do cross into breastmilk. To achieve fatal levels in the infant would have required significant consumption by the mother. Rare, but not unheard of.

Has this happened before???

It's sad to say, but, yes, there are case reports of opioid toxicity on infants as a result of drug abuse in the breastfeeding mother. Some folks have tried to quantify passage of opiates and similar substances into milk; as you can imagine, this is an ethically challenging process. 

[sushi]

I see things from the other side with recovering addicts. I'm full of sympathy for them. They try so hard, but addiction is so tough to kick, even if they were legally prescribed in the beginning.

Sure, it's definitely not fair to innocent babies. But I also hear the self hate and failure from the moms who can't fix it.

Tragedy all around.

[sushi]

Apr 7, 2014 3:48:28 GMT -5 @cse1960 said:

I would be more inclined to think she drugged the child to keep it from crying. Or her dh did. Or both. No way in hell that kid accidentally got enough medication in her to kill an adult just from breastfeeding; it does not seem likely she could even continue sucking that long with that much medication coming in.

And that's where you don't know what you're taking about. A dose a parent takes to feel normal can potentially be a lethal dose to an infant.

[Deleted]

Apr 7, 2014 10:04:04 GMT -5 @cse1960 said:

Apr 7, 2014 5:57:39 GMT -5 sushi said:

And that's where you don't know what you're taking about. A dose a parent takes to feel normal can potentially be a lethal dose to an infant.

The Washington Post article attached said that the amount of morphine found in the child's body was sufficient to be a fatal dose for an ADULT.  The child had enough morphine in her to kill a grown person; this was not a teensy little bit that accidentally got by. And if she actually got that much morphine in her, enough to kill an adult, from breast milk, then her mother must have been really over the limit on how much SHE had taken, to pass on an adult-fatal sized dose to an infant. 


'A toxicology report from the baby’s autopsy found a level of morphine in the child’s body that a pathologist testified could have been lethal for an adult, prosecutor Barry Barnette said.'






Which is why I am suspecting that the baby probably was given some morphine, not just gotten it from the milk. 

If she was an addict, its very possible that the levels she took to get her high were much higher than those that a normal adult would be able to tolerate. Or, if she were in recovery and relapsed, she may have taken a dose comparable to the doses she used to take when she did get high, but that she could no longer tolerate that amount, causing her to feel funny and to kill her child. I know we are all speculating here, but it doesn't seem like there is any evidence that she separately injected the child.

[Deleted]

I assume the baby probably got the morphine more than one way but that breastfeeding was the one definitive method the prosecution had so that's what they went with.

"She was on drugs while breastfeeding her baby and these drugs pass via breastmilk" likely plays better with a jury than "well, we aren't sure how the drugs got into her system but we're pretty sure she's responsible."

[rxbeth]

I have to agree with ColoRxGirl

I'm also a pharmacist and the patches raised a flag for me.  Made me think of fentanyl.

There have been cases of women taking codeine products resulting in infants deaths.  Codeine is actually cautioned in breastfeeding women now because there have been instances of infant deaths with mothers using Tylenol with codeine post partum.  These were not women taking excessive doses.  They were taking the dose recommended by their physicians.  Codeine is actually turned into morphine in the body and there are some nationalities that convert it more effectively than others and these women are at high risk of overdosing an infant.

This is overall unfortunate situation.

[fortmyersbride]

The mixing of transdermal fentanyl and large oral morphine doses suggests she had multiple opioid providers or one provider who wasn't properly trained in chronic pain management. Given that her PCP was prescribing for her without in-person appts, I tend to believe the latter.

All the case reports that I have seen referring to infant opioid overdosing due to breastfeeding are codeine-morphine conversions, caused like rxbeth said by the variability in the way certain individuals metabolize codeine (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61266-0/fulltext#bib3). This situation is somewhat different in that mother was on narcotics throughout the pregnancy and I would have expected the baby to have built up some narcotic tolerance. However given her confusion and disorientation in the 911 call maybe something changed, she doubled up on fent patches or such. I'm also curious as what the concentration of morphine in the infant's blood was.  The lancet article states that a mother taking 100 mg of morphine/day can excrete enough in the breast milk to create a therapeutic level in the infant; chronic pain patients can be tolerant to much much higher doses.

[ColoRxGirl]

Apr 7, 2014 20:52:56 GMT -5 fortmyersbride said:

The mixing of transdermal fentanyl and large oral morphine doses suggests she had multiple opioid providers or one provider who wasn't properly trained in chronic pain management. Given that her PCP was prescribing for her without in-person appts, I tend to believe the latter.

All the case reports that I have seen referring to infant opioid overdosing due to breastfeeding are codeine-morphine conversions, caused like rxbeth said by the variability in the way certain individuals metabolize codeine (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61266-0/fulltext#bib3). This situation is somewhat different in that mother was on narcotics throughout the pregnancy and I would have expected the baby to have built up some narcotic tolerance. However given her confusion and disorientation in the 911 call maybe something changed, she doubled up on fent patches or such. I'm also curious as what the concentration of morphine in the infant's blood was.  The lancet article states that a mother taking 100 mg of morphine/day can excrete enough in the breast milk to create a therapeutic level in the infant; chronic pain patients can be tolerant to much much higher doses.

Agree. In CO, narcotic dispensing is coordinated through a centralized tracking system. Allows us to see if folks are using multiple providers to obtain these agents. Don't know if it would have prevented this situation, but you have to wonder.