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Born Addicted: Neonatal Abstinence Syndrome

January 24, 2014
Lebanon, NH

Bonny Whalen, MD, Newborn Nursery Medical Director at CHaD, talks with women about pre and postnatal care. (Photo by Mark Washburn)

The use of opioids by pregnant women— beyond the need for pain prevention—is creating an alarming increase in neonatal abstinence syndrome (NAS).

NAS, explains Dartmouth-Hitchcock neonatologist William Edwards, MD, occurs when a baby is born with symptoms of withdrawal from in utero opioid exposure. “It really is an epidemic,” says Edwards, the section chief of Neonatology at the Children’s Hospital at Dartmouth-Hitchcock (CHaD.) “A recent article in the Journal of the American Medical Association reported that over a six-year period, from 2003-09, there was over a 600 percent increase in the number of times NAS was diagnosed.”

Babies

Not all babies exposed to opioids in utero have withdrawal symptoms or require treatment. “About 50 percent of the babies we care for have withdrawal symptoms,” says Edwards. “We usually observe newborns for five days for symptoms like irritability, inconsolability, tremulousness, or sometimes difficulty with feeding or diarrhea. The worst-case scenario would be seizures, but that’s pretty uncommon because we would treat before they reach that point.”

The first line of treatment, says Edwards, is non-pharmacological measures: nurturing, breastfeeding, holding, comforting and being with their mothers.

Bonny Whalen, MD, Newborn Nursery medical director at CHaD, who is working with Edwards on NAS, has been doing prenatal visits with women at the River Mill Addiction Treatment Program in Lebanon, NH. “We’ve talked about comfort measures for babies, such as rooming-in, skin-to-skin, gentle rocking/swaying, swaddling and providing calm environments.”

When a baby is suffering from NAS, the average hospital stay is 14-15 days. If the comfort measures are not sufficient the newborn is treated with the drug they were exposed to in utero, likely an opioid. Edwards explains: “We use morphine for treatment; some programs use methadone.” But, Edwards notes, methadone is long acting, and requires an outpatient structure. “With morphine, babies are weaned off in the hospital, and then they can go home not requiring additional medication.”

Mothers

According to Edwards, the real issue is how the mother got involved and addicted to drugs in the first place. “Over half of the women start off by taking drugs that are prescribed for legitimate medical issues, yet continue to take it beyond needing it. This can lead to drug-seeking behaviors. …there isn’t really an exit strategy beyond pain management.”

Fortunately, he says, most of the babies seen at CHaD are babies born to mothers in programs to deal with their addiction. “The vast majority of these babies are withdrawing from methadone or suboxone, or buprenorphine: drugs used to treat opioid addiction. There are, of course, other drugs that babies suffer withdrawal from, like street heroin, or even non-prescribed prescription drugs like Vicodin or Percocet.”

One of the challenges in treating this epidemic, says Edwards, is that approximately 70-75 percent of the women have coexisting psychiatric issues. “Other difficulties include [treatment] programs that just treat the addiction medically, not addressing the psychiatric component. We’ve also found that the majority of the increase in NAS—in New Hampshire and elsewhere—is in Medicaid populations, a marker of socioeconomic issues. It’s not simply a medical problem, it’s a societal problem.”

Solutions

Edwards says that NAS was first brought to his attention in his role as one of the directors of Vermont-Oxford Network (VON)—an international quality improvement network. He soon realized it was a much broader issue. “We know that the issue pre-exists pregnancy and doesn’t go away after discharge. What we really need are services that span that spectrum effectively.”

One regional initiative currently working on this spectrum of care, says Whalen, is a partnership with the Northern New England Perinatal Quality Improvement Network (NNEPQIN). “CHaD is partnering with NNEPQIN, to help increase education of obstetrical and pediatric providers about the risks of in utero opiate exposure, and the ways to improve care of pregnant women and newborns during pregnancy and when they return home to their communities.”  

At the time VON was working on NAS, Edwards learned that a New Hampshire state taskforce was also taking it on under the larger umbrella of overall substance abuse and the two groups merged. Together they are trying to better understand and address the most critical areas of the epidemic. “We not only have a coalition of New Hampshire hospitals participating in this project, but also other hospitals and individual centers from across the country and internationally, with multiple stakeholders involved. It’s a broad brush,” admits Edwards, and still in the nascent stages. Part of the task “is educating ourselves so we can better focus; the issue of access and coordination and continuity of care is huge. Now we are working to develop an action plan.”

Reality

Ultimately, Edwards says, the answer is not treatment programs, but prevention, understanding what leads to addiction and how to avoid it. “We need to understand what is leading to this escalation not only in NAS, but in opioid abuse and addiction. Getting involved in this has certainly opened my eyes to the broader scope.  We need a large and diverse contingent to determine a comprehensive approach to substance abuse, from babies to mothers to families to communities. The cost of this epidemic is quite expensive, both in terms of dollars and human tragedy.”

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