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Hussaini KS, Drummond D, Bartoshesky LE, Acheson A, Stomieroski K, Paul DA, Kirby RS. Assessing the relationship between neonatal abstinence syndrome and birth defects in Delaware. Birth Defects Res 2021; 113:144-151. [PMID: 32996723 PMCID: PMC10947796 DOI: 10.1002/bdr2.1811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) is a withdrawal syndrome in newborns and is frequently caused by maternal opioid use during pregnancy. Our study examines whether NAS is associated with birth defects in Delaware. METHODS We conducted a retrospective analysis of linked Delaware birth certificate data (BCD), hospital discharge data (HDD), and birth defects registry (BDR) data to examine the association between NAS and birth defects for all hospital births to Delaware residents from 2010 to 2017. Birth defects data were abstracted from medical records from Delaware's BDR. We used International Classification of Diseases Ninth and Tenth Revision Clinical Modification (ICD-9-CM/ICD-10-CM) 779.5 and P96.1 codes to determine NAS using HDD and excluded iatrogenic cases of NAS. We estimated crude and adjusted odds ratio with 95% confidence intervals (CIs). RESULTS During 2010-2017, there were 2,784 cases of birth defects and 1,651 cases of NAS in Delaware. Among infants with a diagnosis of NAS, 56 also had a birth defect (3.4%), similar to 2,728 birth defects among 79,636 infants without a diagnosis of NAS (3.4%). We found no statistically significant association between an NAS diagnosis and birth defects (adjusted odds ratios = 1.0; 95% CI: 0.8-1.3). CONCLUSIONS Our multiyear state-wide study using linked BCD, HDD, and BDR data for Delaware did not show a statistically significant association between infants diagnosed with NAS and birth defects, overall.
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Affiliation(s)
- Khaleel S. Hussaini
- Field Support Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
- Division of Public Health, Delaware Department of Health and Social Services, Dover, Delaware
| | - Dana Drummond
- Drug Overdose Surveillance Epidemiologist, Division of Prevention and Community Health, Washington State Department of Health, Tumwater, Washington
| | - Louis E. Bartoshesky
- Pediatrics, ChristianaCare, Newark, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Amy Acheson
- Center for Women’s, Infants’ and Children’s Health Research, ChristianaCare, Newark, Delaware
| | - Kathleen Stomieroski
- Center for Women’s, Infants’ and Children’s Health Research, ChristianaCare, Newark, Delaware
| | - David A. Paul
- Pediatrics, ChristianaCare, Newark, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Russell S. Kirby
- Distinguished Professor and Marrell Endowed Chair, Birth Defects Surveillance ProgramCollege of Public Health, University of South Florida, Tampa, Florida
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102
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Hirai AH, Ko JY, Owens PL, Stocks C, Patrick SW. Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses in the US, 2010-2017. JAMA 2021; 325:146-155. [PMID: 33433576 PMCID: PMC7804920 DOI: 10.1001/jama.2020.24991] [Citation(s) in RCA: 279] [Impact Index Per Article: 93.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Substantial increases in both neonatal abstinence syndrome (NAS) and maternal opioid use disorder have been observed through 2014. OBJECTIVE To examine national and state variation in NAS and maternal opioid-related diagnoses (MOD) rates in 2017 and to describe national and state changes since 2010 in the US, which included expanded MOD codes (opioid use disorder plus long-term and unspecified use) implemented in International Classification of Disease, 10th Revision, Clinical Modification. DESIGN, SETTING, AND PARTICIPANTS Repeated cross-sectional analysis of the 2010 to 2017 Healthcare Cost and Utilization Project's National Inpatient Sample and State Inpatient Databases, an all-payer compendium of hospital discharge records from community nonrehabilitation hospitals in 47 states and the District of Columbia. EXPOSURES State and year. MAIN OUTCOMES AND MEASURES NAS rate per 1000 birth hospitalizations and MOD rate per 1000 delivery hospitalizations. RESULTS In 2017, there were 751 037 birth hospitalizations and 748 239 delivery hospitalizations in the national sample; 5375 newborns had NAS and 6065 women had MOD documented in the discharge record. Mean gestational age was 38.4 weeks and mean maternal age was 28.8 years. From 2010 to 2017, the estimated NAS rate significantly increased by 3.3 per 1000 birth hospitalizations (95% CI, 2.5-4.1), from 4.0 (95% CI, 3.3-4.7) to 7.3 (95% CI, 6.8-7.7). The estimated MOD rate significantly increased by 4.6 per 1000 delivery hospitalizations (95% CI, 3.9-5.4), from 3.5 (95% CI, 3.0-4.1) to 8.2 (95% CI, 7.7-8.7). Larger increases for MOD vs NAS rates occurred with new International Classification of Disease, 10th Revision, Clinical Modification codes in 2016. From a census of 47 state databases in 2017, NAS rates ranged from 1.3 per 1000 birth hospitalizations in Nebraska to 53.5 per 1000 birth hospitalizations in West Virginia, with Maine (31.4), Vermont (29.4), Delaware (24.2), and Kentucky (23.9) also exceeding 20 per 1000 birth hospitalizations, while MOD rates ranged from 1.7 per 1000 delivery hospitalizations in Nebraska to 47.3 per 1000 delivery hospitalizations in Vermont, with West Virginia (40.1), Maine (37.8), Delaware (24.3), and Kentucky (23.4) also exceeding 20 per 1000 delivery hospitalizations. From 2010 to 2017, NAS and MOD rates increased significantly for all states except Nebraska and Vermont, which only had MOD increases. CONCLUSIONS AND RELEVANCE In the US from 2010 to 2017, estimated rates of NAS and MOD significantly increased nationally and for the majority of states, with notable state-level variation.
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Affiliation(s)
- Ashley H. Hirai
- Maternal and Child Health Bureau, Health Resources and Services Administration Department of Health and Human Services, Rockville, Maryland
| | - Jean Y. Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention Department of Health and Human Services, Atlanta, Georgia
- Commissioned Corps Public Health Service Department of Health and Human Services, Rockville, Maryland
| | - Pamela L. Owens
- Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality Department of Health and Human Services, Rockville, Maryland
| | - Carol Stocks
- West Virginia University, School of Public Health, Morgantown
- formerly with the Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality Department of Health and Human Services, Rockville, Maryland at the time of analysis
| | - Stephen W. Patrick
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention Department of Health and Human Services, Atlanta, Georgia
- Department of Pediatrics, Vanderbilt Center for Child Health Policy, Nashville, Tennessee
- Department of Health Policy, Vanderbilt Center for Child Health Policy, Nashville, Tennessee
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee
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103
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Definitions of neonatal abstinence syndrome in clinical studies of mothers and infants: an expert literature review. J Perinatol 2021; 41:1364-1371. [PMID: 33514878 PMCID: PMC8225507 DOI: 10.1038/s41372-020-00893-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/09/2020] [Accepted: 11/20/2020] [Indexed: 01/31/2023]
Abstract
Neonatal abstinence syndrome (NAS) results from discontinuation of in utero exposures to opioids/substances. The rising incidence of NAS has prompted an increased need for accurate research and public health data. To examine how NAS has been defined in clinical studies of opioid-exposed mothers and infants, a review process was developed based on the RAND/UCLA Appropriateness Method, yielding 888 abstracts. Per inclusion criteria, 57 abstracts underwent full-text review. To define NAS, studies cited using modified versions of the Finnegan NAS scoring tool (n = 21; 37%), ICD-9/10 coding (n = 17; 30%), original Finnegan tool (n = 16; 28%), Eat Sleep Console (n = 3; 5%), and Lipsitz (n = 3; 5%) tools, (3 cited 2+ tools). Most studies utilized subjective NAS scoring/assessment algorithms and neonatal coding as key elements defining NAS. While most cited opioid exposure as integral to their inclusion criteria, 26% did not. These approaches highlight the need for a more refined and standardized definition of NAS.
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104
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Kushnir A, Garretson C, Mariappan M, Stahl G. Use of Phenobarbital to Treat Neonatal Abstinence Syndrome From Exposure to Single vs. Multiple Substances. Front Pediatr 2021; 9:752854. [PMID: 35174112 PMCID: PMC8841756 DOI: 10.3389/fped.2021.752854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022] Open
Abstract
Drug use in pregnancy is a major public health issue. Intrauterine exposure to opioids alone or in addition to other substances may lead to neonatal abstinence syndrome (NAS). Little consensus exists on optimal therapy, especially for those exposed to multiple drugs. We aim to determine whether the use of opioids alone vs. in combination with phenobarbital will affect short-term neonatal outcomes. This retrospective review of infants admitted to the neonatal intensive care unit (NICU) included newborns ≥35 weeks of gestation exposed to opioids, or multiple substances including opioids, in utero. Treatment with opioids alone, and addition of phenobarbital as initial therapy vs. rescue, was evaluated. Out of 182 newborns, 54 (30%) were exposed to methadone alone vs. 128 (70%) to multiple drugs. Length of stay (LOS) in the hospital was not significantly affected (p = 0.684) by single vs. multiple drug exposure in utero. Treatment of NAS with opioid alone resulted in significantly shorter LOS (27 days), as compared to those treated with opioid and phenobarbital (45 days, p < 0.001). LOS was further prolonged in those treated with phenobarbital as a "rescue" medication in addition to an opioid (49 days, p < 0.0001). There was a significant increase in LOS and duration of opioid treatment for all infants treated with phenobarbital, both in those exposed to opioids alone, and to multiple substances in utero.
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Affiliation(s)
- Alla Kushnir
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ, United States.,Department of Pediatric, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Cynthia Garretson
- Ambulatory Clinical Practice, Cooper University Hospital, Cherry Hill, NJ, United States
| | - Maheswari Mariappan
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ, United States
| | - Gary Stahl
- Department of Pediatric, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
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105
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Bader MY, Zaghloul N, Repholz A, Nagy N, Ahmed MN, Thompson L, Kylat RI. A Retrospective Review Following the Addition of Clonidine to a Neonatal Abstinence Syndrome Treatment Algorithm. Front Pediatr 2021; 9:632836. [PMID: 34164354 PMCID: PMC8215153 DOI: 10.3389/fped.2021.632836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 05/05/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: To investigate the outcomes associated with the implementation of a neonatal abstinence syndrome (NAS) treatment algorithm utilizing dual therapy with morphine sulfate and clonidine in a level four neonatal intensive care unit (NICU). Study Design: A cohort of neonates (≥35 weeks gestation) born at an academic tertiary medical center between January 1, 2015 and December 31, 2018 who were diagnosed with NAS were retrospectively evaluated following the implementation of a new NAS treatment algorithm. Neonates were categorized in two groups based on if they were treated pre- or post-implementation of the protocol. The primary efficacy outcome was length of hospital stay. Secondary outcomes included the incidence of adverse drug reactions, length of treatment for NAS, and maximum as well as total cumulative dose of each medication used to treat NAS. Results: The implementation of this NAS treatment algorithm significantly reduced the length of hospital stay (30 days vs. 20 days, p = 0.001). In addition, there was a significant decrease in duration of morphine sulfate exposure as well as cumulative dose of morphine required to successfully treat a neonate with NAS in the post-implementation group (26 days vs. 15 days, p = 0.002 and 6.9 mg/kg vs. 3.4 mg/kg, p = 0.031). Conclusion: Addition of clonidine to morphine sulfate as initial therapy for NAS significantly reduced the cumulative exposure as well as duration of exposure to morphine sulfate compared to morphine monotherapy and decrease length of hospital stay.
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Affiliation(s)
- Mohammad Y Bader
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, United States.,Banner University Medical Center, Tucson, AZ, United States
| | - Nahla Zaghloul
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, United States.,Banner University Medical Center, Tucson, AZ, United States
| | - Ashley Repholz
- Las Vegas Children's Hospital, Las Vegas, NV, United States
| | - Nadia Nagy
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, United States.,Banner University Medical Center, Tucson, AZ, United States
| | - Mohamed N Ahmed
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, United States.,Banner University Medical Center, Tucson, AZ, United States
| | | | - Ranjit I Kylat
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, United States.,Banner University Medical Center, Tucson, AZ, United States
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106
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Fucile S, Gallant H, Patel A. Developmental Outcomes of Children Born with Neonatal Abstinence Syndrome (NAS): A Scoping Review. Phys Occup Ther Pediatr 2021; 41:85-98. [PMID: 32495712 DOI: 10.1080/01942638.2020.1766637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AIMS The purpose of this scoping review is to provide an overview of developmental outcomes of children diagnosed with neonatal abstinence syndrome (NAS). METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used to guide this scoping review. A comprehensive search of CINAHL, MEDLINE, EMBASE, Web of Science, and PsycINFO was conducted using search terms related to NAS and developmental areas. Full-text screening was completed for 30 articles, and eight studies were included in this review. RESULTS Cognitive and language development, as well as school performance, social and motor domains, may be areas of concern in children with NAS. CONCLUSIONS The developmental outcomes of infants with NAS cannot be firmly determined due to inconsistent results across reviewed studies. Future research investigating development across various ages is required for rending more appropriate intervention services to this high-risk population.
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Affiliation(s)
- Sandra Fucile
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Haley Gallant
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Anjali Patel
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
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107
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Incidence of Neonatal Abstinence Syndrome Epidemic and Associated Predictors in Nevada: A Statewide Audit, 2016-2018. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010232. [PMID: 33396848 PMCID: PMC7796207 DOI: 10.3390/ijerph18010232] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 11/17/2022]
Abstract
Neonatal abstinence syndrome (NAS) is a postnatal withdrawal syndrome among neonates born to mothers with drug dependence disorders. NAS poses a significant public health challenge nationally, with a six-fold increase in incidence (1.2 to 6.7 per 1000 hospital births/year) from 2000–2016. Besides national data, it is critical to quantify NAS at the state-level to identify target areas for prevention. The objectives of this study were to ascertain statewide burden, including county and regional distribution of NAS in Nevada during 2016–2018, and to investigate potential factors associated with NAS. This study utilized hospital administrative data, and a total of 100,845 inpatient pediatric discharges were examined to identify NAS cases. Statistical analyses included estimation of crude incidence rates per 1000 hospital births and multilevel logistic regression modeling. NAS incidence in Nevada decreased slightly from 8.6 to 7.7 per 1000 hospital births between 2016 and 2018, but the overall incidence of 8 was substantially higher than earlier estimates (4.8/1000 hospital births) reported for 2013. Incidence was disproportionately higher among white newborns (12, 95% CI 11.0,13.0) and Medicaid enrollees (13.2, 95% CI 11.0,15.0). Southern Nevada had the highest incidence rate of 8.2 per 1000 hospital births. Nearly 75% of NAS cases were residents of Clark County. Incidence rates of NAS parallel the growing opioid prescription rates in Nevada and highlight the need for adopting opioid control prescribing practices to combat this drug epidemic. These findings might help in designing and evaluating state- and system-level interventions introduced to combat the opioid epidemic.
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108
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Wijekoon N, Aduroja O, Biggs JM, El-Metwally D, Gopalakrishnan M. Model-Based Approach to Improve Clinical Outcomes in Neonates With Opioid Withdrawal Syndrome Using Real-World Data. Clin Pharmacol Ther 2020; 109:243-252. [PMID: 33119888 DOI: 10.1002/cpt.2093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/11/2020] [Indexed: 12/13/2022]
Abstract
At least 60% of the neonates with opioid withdrawal syndrome (NOWS) require morphine to control withdrawal symptoms. Currently, the morphine dosing strategies are empiric, not optimal and associated with longer hospital stay. The aim of the study was to develop a quantitative, model-based, real-world data-driven approach to morphine dosing to improve clinical outcomes, such as reducing time on treatment. Longitudinal morphine dose, clinical response (Modified Finnegan Score (MFS)), and baseline risk factors were collected using a retrospective cohort design from the electronic medical records of neonates with NOWS (N = 177) admitted to the University of Maryland Medical Center. A dynamic linear mixed effects model was developed to describe the relationship between MFS and morphine dose adjusting for baseline risk factors using a split-sample data approach (70% training: 30% test). The training model was evaluated in the test dataset using a simulation based approach. Maternal methadone and benzodiazepine use, and race were significant predictors of the MFS response. Positive autocorrelations of 0.56 and 0.12 were estimated between consecutive MFS responses. On an average, for a 1,000 μg increase in the morphine dose, the MFS decreased by 0.3 units. The model evaluation showed that observed and predicted median time on treatment were similar (13.0 vs. 13.8 days). A model-based framework was developed to describe the MFS-morphine dose relationship using real-world data that could potentially be used to develop an adaptive, individualized morphine dosing strategy to improve clinical outcomes in infants with NOWS.
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Affiliation(s)
- Nadeesri Wijekoon
- Department of Mathematics and Statistics, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Oluwatobi Aduroja
- Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Jessica M Biggs
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Dina El-Metwally
- Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
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109
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Fallin-Bennett A, Lofwall M, Waters T, Nuzzo P, Barnett J, Ducas L, McCubbin A, Chavan N, Blair L, Ashford K. Behavioral and Enhanced Perinatal Intervention (B-EPIC): A randomized trial targeting tobacco use among opioid dependent pregnant women. Contemp Clin Trials Commun 2020; 20:100657. [PMID: 33294725 PMCID: PMC7689271 DOI: 10.1016/j.conctc.2020.100657] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/11/2020] [Accepted: 09/29/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Opioid use during pregnancy is a significant public health issue. The standard of care for treating opioid use disorder during pregnancy includes medications for opioid disorder (MOUD). However, tobacco use often goes unaddressed among pregnant women on MOUD. In 2018, our team received a National Institute on Drug Abuse (NIDA) funded R34 to conduct a three year-randomized trial to test the feasibility of a novel tobacco intervention for pregnant women receiving MOUD. AIMS The aims of this study are: (1) to determine the impact of the B-EPIC intervention on maternal tobacco use and stage of change; (2) to determine the impact of B-EPIC on tobacco-related maternal and infant health outcomes including gestational age at birth, birthweight, NAS diagnosis and severity, and number of ear and respiratory infections during the first six months; (3) to compare healthcare utilization and costs incurred by pregnant patients that receive the B-EPIC intervention versus TAU. METHODS We plan to enroll 100 pregnant women on MOUD for this randomized controlled trial (B-EPIC intervention n = 50 and treatment as usual n = 50). A major strength of this study is its wide range of health and economic outcomes assessed on mother, neonate and the infant. CONCLUSIONS Despite the very high rates of smoking among pregnant women with OUD, there are few tobacco treatment interventions that have been tailored for this high - risk population. The overall goal of this study is to move towards a tobacco treatment standard for pregnant women receiving treatment for OUD.
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Affiliation(s)
- Amanda Fallin-Bennett
- University of Kentucky College of Nursing, Perinatal Research and Wellness Center, Kentucky (KY), USA
| | - Michelle Lofwall
- University of Kentucky Department of Behavioral Science & Psychiatry, Center on Drug and Alcohol Research, Kentucky (KY), USA
| | - Teresa Waters
- University of Kentucky College of Public Health, Kentucky (KY), USA
| | - Paul Nuzzo
- University of Kentucky Department of Behavioral Science & Psychiatry, Center on Drug and Alcohol Research, Kentucky (KY), USA
| | - Janine Barnett
- University of Kentucky College of Nursing, Perinatal Research and Wellness Center, Kentucky (KY), USA
| | - Letitia Ducas
- University of Kentucky College of Nursing, Perinatal Research and Wellness Center, Kentucky (KY), USA
| | - Andrea McCubbin
- University of Kentucky College of Nursing, Perinatal Research and Wellness Center, Kentucky (KY), USA
| | - Niraj Chavan
- University of Kentucky College of Medicine, Department of Obstetrics & Gynecology, Kentucky (KY), USA
| | - Lisa Blair
- University of Kentucky College of Nursing, Perinatal Research and Wellness Center, Kentucky (KY), USA
| | - Kristin Ashford
- University of Kentucky College of Nursing, Perinatal Research and Wellness Center, Kentucky (KY), USA
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110
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Peeler M, Gupta M, Melvin P, Bryant AS, Diop H, Iverson R, Callaghan K, Wachman EM, Singh R, Houghton M, Greenfield SF, Schiff DM. Racial and Ethnic Disparities in Maternal and Infant Outcomes Among Opioid-Exposed Mother-Infant Dyads in Massachusetts (2017-2019). Am J Public Health 2020; 110:1828-1836. [PMID: 33058701 PMCID: PMC7661985 DOI: 10.2105/ajph.2020.305888] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2020] [Indexed: 11/04/2022]
Abstract
Objectives. To examine the extent to which differences in medication for opioid use disorder (MOUD) in pregnancy and infant neonatal opioid withdrawal syndrome (NOWS) outcomes are associated with maternal race/ethnicity.Methods. We performed a secondary analysis of a statewide quality improvement database of opioid-exposed deliveries from January 2017 to April 2019 from 24 hospitals in Massachusetts. We used multivariable mixed-effects logistic regression to model the association between maternal race/ethnicity (non-Hispanic White, non-Hispanic Black, or Hispanic) and prenatal receipt of MOUD, NOWS severity, early intervention referral, and biological parental custody at discharge.Results. Among 1710 deliveries to women with opioid use disorder, 89.3% (n = 1527) were non-Hispanic White. In adjusted models, non-Hispanic Black women (AOR = 0.34; 95% confidence interval [CI] = 0.18, 0.66) and Hispanic women (AOR = 0.43; 95% CI = 0.27, 0.68) were less likely to receive MOUD during pregnancy compared with non-Hispanic White women. We found no statistically significant associations between maternal race/ethnicity and infant outcomes.Conclusions. We identified significant racial/ethnic differences in MOUD prenatal receipt that persisted in adjusted models. Research should focus on the perspectives and treatment experiences of non-Hispanic Black and Hispanic women to ensure equitable care for all mother-infant dyads.
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Affiliation(s)
- Mary Peeler
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Munish Gupta
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Patrice Melvin
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Allison S Bryant
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Hafsatou Diop
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Ronald Iverson
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Katherine Callaghan
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Elisha M Wachman
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Rachana Singh
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Mary Houghton
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Shelly F Greenfield
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
| | - Davida M Schiff
- Mary Peeler is with the Johns Hopkins School of Medicine, Baltimore, MD. Munish Gupta and Mary Houghton are with the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA. Patrice Melvin is with Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston. Allison S. Bryant is with the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston. Hafsatou Diop is with the Massachusetts Department of Public Health, Boston. Ronald Iverson is with the Department of Obstetrics and Gynecology, Boston Medical Center, Boston. Katherine Callaghan is with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worchester, MA. Elisha M. Wachman is with the Division of Neonatology, Department of Pediatrics, Boston Medical Center. Rachana Singh is with the Division of Newborn Medicine, Baystate Children's Hospital, Springfield, MA. Shelly F. Greenfield is with the Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA. Davida M. Schiff is with the Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston
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Hurley EA, Duello A, Finocchario-Kessler S, Goggin K, Stancil S, Winnograd RP, Miller MK. Expanding Contraception Access for Women With Opioid-Use Disorder: A Qualitative Study of Opportunities and Challenges. Am J Health Promot 2020; 34:909-918. [PMID: 32468826 PMCID: PMC7577934 DOI: 10.1177/0890117120927327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE As almost nine in ten pregnancies among women with opioid use disorder (OUD) are unintended, expanding access to contraception is an underutilized but potentially effective strategy in increasing reproductive agency and reducing the overall burden of neonatal abstinence syndrome. We aimed to identify where and how contraceptive services could be integrated into existing points-of-contact for women with OUD. APPROACH In-depth qualitative interviews. SETTING Three diverse catchment areas in Missouri. PARTICIPANTS Women with OUD (n = 15) and professional stakeholders (n = 16) representing five types of existing OUD service points: syringe exchange programs, recovery support programs, substance use treatment programs, emergency departments, and Federally Qualified Health Centers. METHOD Interviews were audio-recorded, transcribed, and thematically coded using Dedoose software. RESULTS Six themes emerged as essential components for integrating contraceptive services into existing points-of-contact for women with OUD: (1) reach women with unmet need; (2) provide free or affordable contraception; (3) maximize service accessibility; (4) provide patient-centered care; (5) employ willing, qualified contraceptive providers; and (6) utilize peer educators. Participants affirmed the overall potential benefit of contraceptive service integration and illuminated various opportunities and challenges relevant to each type of existing service point. CONCLUSION As health promotion initiatives look to increase access to contraception among women with OUD, these six' participant-identified components offer essential guidance in selecting advantageous points-of-contact and addressing remaining gaps in services.
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Affiliation(s)
- Emily A. Hurley
- Division of Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City, MO, USA
- Department of Pediatric, School of Medicine, University of Missouri–Kansas City, Kansas City, MO, USA
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - Alex Duello
- Missouri Institute of Mental Health, University of Missouri–St. Louis, St. Louis, MO, USA
| | | | - Kathy Goggin
- Division of Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City, MO, USA
- Department of Pediatric, School of Medicine, University of Missouri–Kansas City, Kansas City, MO, USA
- School of Pharmacy, University of Missouri–Kansas City, Kansas City, MO, USA
| | - Stephani Stancil
- Dvisions of Adolescent Medicine and Clinical Pharmacology, Children’s Mercy Kansas City, Kansas City, MO, USA
| | - Rachel P. Winnograd
- Missouri Institute of Mental Health, University of Missouri–St. Louis, St. Louis, MO, USA
| | - Melissa K. Miller
- Department of Pediatric, School of Medicine, University of Missouri–Kansas City, Kansas City, MO, USA
- Emergency Medicine, Children’s Mercy Kansas City, Kansas City, MO, USA
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Rees P, Stilwell PA, Bolton C, Akillioglu M, Carter B, Gale C, Sutcliffe A. Childhood Health and Educational Outcomes After Neonatal Abstinence Syndrome: A Systematic Review and Meta-analysis. J Pediatr 2020; 226:149-156.e16. [PMID: 32659230 DOI: 10.1016/j.jpeds.2020.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To systematically review and meta-analyze the association between neonatal abstinence syndrome (NAS) and adverse health or educational childhood outcomes. STUDY DESIGN An all-language search was conducted across 11 databases between January 1, 1975, and September 3, 2019; 5865 titles were identified. Observational studies of children between 28 days and 16 years of age, in whom a diagnosis of NAS was documented, were included. Outcomes included reasons for hospital admissions, childhood diagnoses, developmental outcomes, and academic attainment scores. All studies underwent independent review by 2 trained reviewers, who extracted study data and assessed risk of bias using the Newcastle Ottawa Tool. RESULTS Fifteen studies were identified that included 10 907 children with previous NAS and 1 730 213 children without previous NAS, aged 0-16 years. There was a strong association between NAS and subsequent child maltreatment (aOR, 6.49; 95% CI, 4.46-9.45; I2 = 52%), injuries and poisoning (aOR, 1.34; 95% CI, 1.21-1.49; I2 = 0%), and a variety of mental health conditions. Studies consistently demonstrated an increased incidence of strabismus and nystagmus among those with previous NAS. Children with NAS also had lower mean academic scores than the control group in every domain of testing across age groups. CONCLUSIONS NAS is significantly associated with future child maltreatment, mental health diagnoses, visual problems, and poor school performance. Owing to the necessary inclusion of nonrandomized studies, incomplete reporting among studies, and likely unadjusted confounding, this review does not suggest causation. However, we highlight associations requiring further investigation and targeted intervention, to positively impact the life course trajectories of this growing population of children.
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Affiliation(s)
- Philippa Rees
- Population Policy Practice, NIHR BRC UCL Institute of Child Health, University College London, UK.
| | | | - Chrissy Bolton
- Whittington Health National Health Service Trust, London, UK
| | | | - Ben Carter
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Imperial College London, UK
| | - Alastair Sutcliffe
- Population Policy Practice, NIHR BRC UCL Institute of Child Health, University College London, UK
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Roca A, Jarque P, Gomila I, Marchei E, Tittarelli R, Elorza MÁ, Sanchís P, Barceló B. [Clinical features and risk factors associated with prenatal exposure to drugs of abuse]. An Pediatr (Barc) 2020; 95:S1695-4033(20)30285-X. [PMID: 33041240 DOI: 10.1016/j.anpedi.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Early identification of neonates exposed to drugs of abuse during pregnancy allows a more precise clinical management. OBJECTIVES To describe the clinical characteristics and to identify risk factors associated with the early detection of neonates exposed to drugs of abuse in a Neonatal Intermediate and Intensive Care Unit. METHODS Prospective observational study of neonates with and without clinical suspicion of prenatal exposure to drugs of abuse. Meconium was analyzed using standard chromatographic techniques. Univariate and multivariate statistical analyzes were performed. RESULTS 372 neonates were included. Exposure to drugs of abuse was detected in 49 (13.2%) cases: in 41 (83.7%) one drug and in 8 (16.3%) more than one. Somatometry at birth revealed: a) lower length percentile in those exposed to some drug, more than one and cannabis; b) lower weight percentile in those exposed to cannabis and of these compared to those exposed to alcohol. In neonates older than 34 pregnancy weeks (PW): a) lower length percentile in those exposed to any substance; b) lower percentile of length and weight in exposed to more than one. The most clinically relevant independent risk factors useful to detect cases of prenatal exposure to drugs of abuse were (Odds ratio (95% CI)): reason for admission other than prematurity (5.52 (2.55-1.93)), length percentile less than 33 (1.95 (1.05-3.60) and 2.14 (1.04-3.40) in older than 34 PW) and social dystocia/uncontrolled pregnancy in older than 34 PW (4.47 (1.03-19.29)). CONCLUSIONS There are somatometric alterations and risk factors that can help in the early detection of neonates exposed to drugs of abuse. The somatometric alterations identified can be useful to extend the differential diagnosis of these alterations and to study their causes.
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Affiliation(s)
- Antonia Roca
- Unidad de Neonatología, Servicio de Pediatría, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - Pilar Jarque
- Unidad de Neonatología, Servicio de Pediatría, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - Isabel Gomila
- Servicio de Análisis Clínicos, Hospital Universitario Son Llàtzer, Palma de Mallorca, España; Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, España
| | - Emilia Marchei
- Centro Nacional de Adicciones y Dopaje, Instituto Superior de Salud, Roma, Italia
| | - Roberta Tittarelli
- Unidad de Toxicología Forense, Departamento de Ciencias Anatómicas, Histológicas, Forenses y Ortopédicas, Universidad de Sapienza, Roma, Italia
| | - Miguel Ángel Elorza
- Servicio de Análisis Clínicos, Unidad de Toxicología Clínica, Hospital Universitario Son Espases, Palma de Mallorca, España; Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, España
| | - Pilar Sanchís
- Departamento de Química, Universidad de las Islas Baleares, Palma de Mallorca, España; Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, España
| | - Bernardino Barceló
- Servicio de Análisis Clínicos, Unidad de Toxicología Clínica, Hospital Universitario Son Espases, Palma de Mallorca, España; Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, España.
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Tabi S, Heitner SA, Shivale S, Minchenberg S, Faraone SV, Johnson B. Opioid Addiction/Pregnancy and Neonatal Abstinence Syndrome (NAS): A Preliminary Open-Label Study of Buprenorphine Maintenance and Drug Use Targeted Psychotherapy (DUST) on Cessation of Addictive Drug Use. Front Psychiatry 2020; 11:563409. [PMID: 33173512 PMCID: PMC7538830 DOI: 10.3389/fpsyt.2020.563409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/14/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) is common, expensive, and hurts opioid addicted women and their families. Current treatments do not sufficiently address comorbid addictions, especially tobacco use, among pregnant buprenorphine-maintained women. METHODS 25 consecutive admissions of pregnant, opioid addicted women were treated with buprenorphine maintenance and a novel intervention for pregnant opioid addicted patients, Drug Use Targeted Therapy (DUST). DUST entails a combination of informing women about the impact of various drugs on their fetus, discussing the woman's thinking about these consequences of drug use, and varying the frequency of psychotherapy; increasing if addictive drugs are used and decreasing if the woman wishes when drug use is stopped. RESULTS 20/25 remained in treatment until delivery. All 20 women were using addictive drugs at admission. None were planned pregnancies. There was a high prevalence of emotional, physical or sexual abuse, criminal behavior, comorbid psychiatric disorders, and chronic pain. Nineteen stopped all addictive drugs. NAS was present for 5 out of 19 newborns with a duration of hospitalization from 4 to 6 days. CONCLUSIONS This preliminary open-label case series found that pregnant buprenorphine maintained women can stop tobacco. What has sometimes been termed "neonatal opioid abstinence syndrome" may most accurately be termed, "neonatal opioid/tobacco abstinence syndrome." If the treatment effectively addresses tobacco use, other addictive drugs are rarely used. DUST resulted in a 95% quit rate for addictive drugs. Pilot data on this new intervention is limited; a case series that does not have a corresponding control group.
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Affiliation(s)
- Sarah Tabi
- Department of Psychiatry, State University of New York Upstate Medical University, Syracuse, NY, United States
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sarah A. Heitner
- Department of Psychiatry, State University of New York Upstate Medical University, Syracuse, NY, United States
| | - Swati Shivale
- Department of Psychiatry, State University of New York Upstate Medical University, Syracuse, NY, United States
- Department of Psychiatry, Bellevue Hospital Centre and New York University School of Medicine, New York, NY, United States
| | - Scott Minchenberg
- Department of Psychiatry, State University of New York Upstate Medical University, Syracuse, NY, United States
- Department of Medicine, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, MA, United States
| | - Stephen V. Faraone
- Department of Psychiatry, State University of New York Upstate Medical University, Syracuse, NY, United States
| | - Brian Johnson
- Department of Psychiatry, State University of New York Upstate Medical University, Syracuse, NY, United States
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Physiologic Indirect Response Modeling to Describe Buprenorphine Pharmacodynamics in Newborns Treated for Neonatal Opioid Withdrawal Syndrome. Clin Pharmacokinet 2020; 60:249-259. [PMID: 32939690 DOI: 10.1007/s40262-020-00939-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND OBJECTIVE Buprenorphine has been shown to be effective in treating infants with neonatal opioid withdrawal syndrome. However, an evidence-based buprenorphine dosing strategy has not been established in the treatment of neonatal opioid withdrawal syndrome because of a lack of exposure-response data. The aim of this study was to develop an integrated pharmacokinetic and pharmacodynamic model to predict buprenorphine treatment outcomes in newborns with neonatal opioid withdrawal syndrome. METHODS Clinical data were obtained from 19 newborns with a median (range) gestational age of 37 (34-41) weeks enrolled in a pilot pharmacokinetic study of buprenorphine. Sparse blood sampling, comprising three specimens obtained around the second dose of buprenorphine, was performed using heel sticks with dried blood spot technology. Standardized neonatal opioid withdrawal syndrome severity scores (Finnegan scores) were collected every 3-4 h based on symptoms by bedside nursing staff. Mean Finnegan scores were used as a pharmacodynamic marker in the exposure-response modeling. The blood concentration-Finnegan score relationship was described using a physiologic indirect response model with inclusion of natural disease remission. RESULTS A total of 52 buprenorphine blood concentrations and 780 mean Finnegan scores were available for the pharmacokinetic/pharmacodynamic modeling and exposure-response analysis. A one-compartment model with first-order absorption adequately described the pharmacokinetic data. The buprenorphine blood concentration at 50% of maximum effect for the inhibition of disease progression was 0.77 ng/mL (95% confidence interval 0.32-1.2). The inclusion of natural disease remission described as a function of postnatal age significantly improved the model fit. CONCLUSIONS A buprenorphine pharmacokinetic/pharmacodynamic model was successfully developed. The model could facilitate model-informed optimization of the buprenorphine dosing regimen in the treatment of neonatal opioid withdrawal syndrome.
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Dopp A, Zabel Thornton M, Kozhimannil K, Jones CW, Greenfield B. Hospital care for opioid use disorder in pregnancy: Challenges and opportunities identified from a Minnesota survey. ACTA ACUST UNITED AC 2020; 16:1745506520952006. [PMID: 32833589 PMCID: PMC7448132 DOI: 10.1177/1745506520952006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: The prevalence of opioid use disorder continues to rise in the United States, with a simultaneous increase in the diagnosis of both opioid use disorder during pregnancy and neonatal opioid withdrawal syndrome. Despite these increases in pregnancy-related care, little is known about hospital policy and policy implementation related to opioid use disorder in pregnancy. In addition, it is unknown whether policies might differ in rural or urban hospitals. To better examine these issues, Minnesota hospitals were surveyed regarding the existence and implementation of policies related to opioid use disorder in pregnancy and whether any policy implementation challenges had been identified. Methods: From August to December 2017, the research team contacted all Minnesota hospitals that offered obstetric services (n = 82) to survey challenges to implementing policies for opioid use disorder during pregnancy, among other questions. Fifty-nine hospitals had respondents (primarily obstetric department supervisors) who provided information about policy implementation challenges for a 72% response rate. Qualitative responses were analyzed using qualitative description and according to hospital location: metropolitan (urban), micropolitan (rural), or non-core (rural). Results: Ninety-one percent of respondents said that they had pregnancies affected by opioid use disorder at their hospital within the last year. Four major challenges to policy implementation were identified in qualitative responses: (1) provider consensus, (2) patient response to policy, (3) lack of resources, and (4) low frequency of occurrence. All four challenges were more frequently identified by respondents at rural hospitals compared to urban hospitals. Conclusion: This study identified challenges in standardizing hospital care for pregnancies affected by opioid use disorder, and these challenges were identified more frequently in rural locations. These non-urban hospitals may require increased state and federal support and funding.
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Affiliation(s)
- Alana Dopp
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth, MN, USA
| | - Morgan Zabel Thornton
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth, MN, USA
| | - Katy Kozhimannil
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Cresta W Jones
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Brenna Greenfield
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth, MN, USA
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Alsaleem M, Berkelhamer SK, Wilding GE, Miller LM, Reynolds AM. Effects of Partially Hydrolyzed Formula on Severity and Outcomes of Neonatal Abstinence Syndrome. Am J Perinatol 2020; 37:1177-1182. [PMID: 31238343 DOI: 10.1055/s-0039-1692684] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE This study compares the effect of partially hydrolyzed formula (PHF) and standard formula (SF) on the severity and short-term outcomes of neonatal abstinence syndrome (NAS). STUDY DESIGN We performed a retrospective chart review of 124 opioid-dependent mothers and their term or near-term infants. Infants were categorized according to the predominant type of formula consumed during the hospital stay. Finnegan's scale was used to assess symptoms of withdrawal. RESULTS A total of 110 infants met our inclusion criteria. Thirty-four (31%) infants were fed predominantly PHF, 60 (54%) infants were fed SF, and 16 (15%) infants were fed maternal breast milk. There was no difference between the infants in the PHF and SF groups with respect to requirement of morphine (MSO4) therapy, maximum dose of MSO4 used, duration of MSO4 treatment or length of hospital stay after performing multivariate analyses to control for type of drug used by the mother, maternal smoking, regular prenatal care, inborn status, and maximum Finnegan score prior to MSO4 treatment. CONCLUSION Use of PHF failed to impact short-term outcomes in infants treated for NAS including maximum MSO4 dose, duration of MSO4 treatment, and length of hospital stay. A prospective randomized controlled trial may be indicated to confirm this finding.
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Affiliation(s)
- Mahdi Alsaleem
- Division of Neonatal-Perinatal Medicine, The State University of New York at Buffalo, Buffalo, New York
| | - Sara K Berkelhamer
- Division of Neonatal-Perinatal Medicine, The State University of New York at Buffalo, Buffalo, New York
| | - Gregory E Wilding
- Department of Biostatistics, The State University of New York at Buffalo, Buffalo, New York
| | - Lorin M Miller
- Department of Biostatistics, The State University of New York at Buffalo, Buffalo, New York
| | - Anne Marie Reynolds
- Division of Neonatal-Perinatal Medicine, The State University of New York at Buffalo, Buffalo, New York
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Danis DO, Bachrach K, Piraquive J, Marston AP, Levi JR. Cleft Lip and Palate in Newborns Diagnosed With Neonatal Abstinence Syndrome. Otolaryngol Head Neck Surg 2020; 164:199-205. [PMID: 32689883 DOI: 10.1177/0194599820944899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Cleft lip and/or cleft palate (CLP) is the most common major congenital malformation of the head and neck. Previous studies suggested an association between fetal opioid exposure and CLP. This study seeks to evaluate the associations between CLP and neonatal abstinence syndrome (NAS) in the United States. STUDY DESIGN Population-based inpatient registry analysis. SETTING Academic medical center. SUBJECTS AND METHODS Kids' Inpatient Database (2016) was used to identify weighted in-hospital births with diagnoses of CLP or NAS. Demographic information was obtained. RESULTS Among 3.8 million weighted in-hospital births, prevalence rates of CLP in the NAS and non-NAS populations were 3.13 and 1.35 per 1000, respectively. The odds ratios for patients with NAS developing CLP, isolated cleft palate, isolated cleft lip, and cleft lip and palate when compared with the reference population were 2.33 (95% CI, 1.87-2.91; P < .001), 4.97 (95% CI, 3.84-6.43; P < .001), 1.01 (P = .98), and 0.80 (P = .46). Independent predictors of CLP within the NAS population included median household income for patients' zip code, race, hospital region, payment method, and maternal use of tobacco or other drugs of addiction. The binary logistic regression model accounting for possible confounding variables produced an odds ratio of 1.74 (95% CI, 1.36-2.23; P < .001) for the association between NAS and CLP. CONCLUSION Our study found an association between NAS and CLP, specifically isolated cleft palate, suggesting that prenatal exposure to opioids may be an environmental risk factor in the development of CLP.
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Affiliation(s)
| | - Kevin Bachrach
- School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Jacquelyn Piraquive
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA
| | - Alexander P Marston
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jessica R Levi
- School of Medicine, Boston University, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA
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119
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Brusseau C, Burnette T, Heidel RE. Clonidine versus phenobarbital as adjunctive therapy for neonatal abstinence syndrome. J Perinatol 2020; 40:1050-1055. [PMID: 32424335 DOI: 10.1038/s41372-020-0685-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/06/2020] [Accepted: 04/30/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare clonidine versus phenobarbital as adjunctive therapy in infants who failed monotherapy with morphine for neonatal abstinence syndrome (NAS). STUDY DESIGN Prospective, randomized, open-label study of infants ≥ 35 weeks' gestation. Infants received clonidine or phenobarbital per protocol. Primary outcome was morphine treatment days. Secondary outcomes were inpatient adjunctive days, length of stay (LOS), triple therapy, safety, and readmission rates. RESULTS A total of 25 infants were treated with clonidine (n = 14) or phenobarbital (n = 11). Mean morphine treatment duration was significantly longer with clonidine (34.4 days, SD = 10.6) compared with phenobarbital (25.5 days, SD = 7.3, p = 0.026). The clonidine group also had higher inpatient adjunctive days (mean: 33.8 days [SD = 14.3] vs. 22 days [SD = 12.6], p = 0.042) and LOS (mean: 41.8 days [SD = 10.9] vs. 31 days [SD = 10]; p = 0.018) compared with phenobarbital. CONCLUSIONS Phenobarbital, as adjunctive therapy, led to significantly shorter duration of morphine therapy, inpatient adjunctive days, and length of stay compared with clonidine.
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Affiliation(s)
- Carrie Brusseau
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA.
| | - Tara Burnette
- Department of Neonatology, University of Tennessee Medical Center, Knoxville, TN, USA
| | - R Eric Heidel
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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120
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Knowledge of and Perceived Competence in Trauma-Informed Care and Attitudes of NICU Nurses Toward Mothers of Newborns With Neonatal Abstinence Syndrome. J Obstet Gynecol Neonatal Nurs 2020; 49:373-387. [PMID: 32553592 DOI: 10.1016/j.jogn.2020.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To explore how knowledge of and perceived competence in trauma-informed care inform the attitudes of NICU nurses toward mothers of newborns with neonatal abstinence syndrome (NAS). DESIGN A cross-sectional survey study. SETTING A southern U.S. metropolitan children's hospital with 145 NICU beds. PARTICIPANTS Convenience sample of 150 NICU nurses. METHODS Participants completed an online survey questionnaire adapted from the Attitudes About Drug Abuse in Pregnancy questionnaire and the Trauma-Informed Pediatric Care survey. Participants also responded to one open-ended question about their experiences in working with mothers of newborns with NAS. We used descriptive and inferential statistics and content analysis to analyze the survey data. RESULTS Participants demonstrated low to moderate knowledge about and perceived competence in trauma-informed care and showed more judgmental attitudes toward mothers of newborns with NAS. Level of knowledge about mothers with substance use disorder and perceived competence in trauma-informed care were associated with participants' attitudes toward mothers of newborns with NAS. Emergent themes from qualitative data included the following: Mother-Newborn Dyads Shape Nurses' Judgmental Attitudes, Caring for Mothers of Newborns With NAS Is a Challenging Experience, and Need to Refine Care for Mothers Through Intra- and Interdisciplinary Collaboration. CONCLUSION NICU nurses need further education about mothers of newborns with NAS. Improved knowledge about these women and adaptation of the principles of trauma-informed care may influence NICU nurses' judgmental attitudes toward mothers of newborns with NAS.
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121
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Affiliation(s)
- Kimberly J Templeton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
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122
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Woodruff K, Roberts SCM. "Alcohol During Pregnancy? Nobody Does That Anymore": State Legislators' Use of Evidence in Making Policy on Alcohol Use in Pregnancy. J Stud Alcohol Drugs 2020. [PMID: 31250804 DOI: 10.15288/jsad.2019.80.380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE In recent years, U.S. states have passed many laws addressing alcohol use in pregnancy, despite limited evidence on the impact of such policies. This study explores how state legislators use evidence when making policy on alcohol use in pregnancy. METHOD Study data are drawn from semistructured interviews with 29 state lawmakers and their aides in Maryland, North Carolina, and Virginia, conducted in March through July 2017. Interview transcripts were coded and analyzed by inductive and deductive methods. RESULTS Despite evidence on the harms of alcohol use in pregnancy, most lawmakers did not express concern about this topic. Instead, they expressed concern about opioid use in pregnancy. Personal experiences, anecdotes, and known contacts influenced legislators' views on substance use in pregnancy, whereas evidence, for the most part, did not. The intermediaries who typically bring evidence about problems and solutions to legislators did not appear to be raising the issue of alcohol use in pregnancy on legislators' agenda. CONCLUSIONS Basic evidence on the prevalence and harms of alcohol use in pregnancy did not appear to influence state lawmakers' policy priorities. Concern over opioid use in general may provide a window of opportunity to educate legislators on the relative scope and harms of alcohol and opioid use in pregnancy. It remains unclear why states are passing alcohol-in-pregnancy policies. More research is needed to explore how state lawmakers form their understanding of substance use in pregnancy and related policies.
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Affiliation(s)
- Katie Woodruff
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Sarah C M Roberts
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Oakland, California
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123
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Auger N, Low N, Carrier FM, Ayoub A, Luu TM. Maternal prepregnancy surgery and risk of neonatal abstinence syndrome in future newborns: a longitudinal cohort study. CMAJ 2020; 191:E779-E786. [PMID: 31308006 DOI: 10.1503/cmaj.181519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Neonatal abstinence syndrome is increasingly prevalent, and may be related to opioid use disorders caused by postoperative prescriptions for pain control. We assessed the association of maternal prepregnancy surgery with risk of neonatal abstinence syndrome from opioid use disorders in future pregnancies. METHODS We conducted a longitudinal retrospective cohort study of 2 182 365 deliveries in Quebec, Canada, between 1989 and 2016. The main exposure was maternal prepregnancy surgery. The main outcome measure was neonatal abstinence syndrome in offspring. We adjusted associations for maternal comorbidity and pregnancy characteristics using log-binomial regression models. RESULTS The prevalence of neonatal abstinence syndrome in the cohort was 10.7 per 10 000 births. Compared with no surgery, prepregnancy surgery was associated with a risk ratio (RR) of neonatal abstinence syndrome of 1.63 (95% confidence interval [CI] 1.49-1.78). Risk was greater for 3 or more prepregnancy surgeries (RR 2.34, 95% CI 2.07-2.63) and age < 15 years at first surgery (1 surgery: RR 2.08, 95% CI 1.71-2.54; 2 or more surgeries: RR 2.79, 95% CI 2.32-3.37). Nearly all surgical specialties increased the risk of neonatal abstinence syndrome, but associations were strongest for cardiothoracic surgery (RR 4.45, 95% CI 2.87-6.91), neurosurgery (RR 3.00, 95% CI 1.56-5.77) and urologic surgery (RR 3.03, 95% CI 2.16-4.26). INTERPRETATION Prepregnancy surgery is associated with the risk of neonatal abstinence syndrome in future pregnancies. Prescription opioids for postsurgical pain may result in opioid use disorders during future pregnancies, inadvertently increasing the risk of neonatal abstinence syndrome in offspring.
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Affiliation(s)
- Nathalie Auger
- University of Montreal Hospital Research Centre (Auger, Carrier, Ayoub), School of Public Health; Institut national de santé publique du Québec (Auger, Ayoub); Department of Psychiatry (Low), McGill University; Departments of Anesthesiology and Medicine (Carrier), Critical Care Division, University of Montreal Hospital; Department of Pediatrics (Luu), Sainte-Justine Hospital Research Centre, University of Montreal, Montréal, Que.
| | - Nancy Low
- University of Montreal Hospital Research Centre (Auger, Carrier, Ayoub), School of Public Health; Institut national de santé publique du Québec (Auger, Ayoub); Department of Psychiatry (Low), McGill University; Departments of Anesthesiology and Medicine (Carrier), Critical Care Division, University of Montreal Hospital; Department of Pediatrics (Luu), Sainte-Justine Hospital Research Centre, University of Montreal, Montréal, Que
| | - François M Carrier
- University of Montreal Hospital Research Centre (Auger, Carrier, Ayoub), School of Public Health; Institut national de santé publique du Québec (Auger, Ayoub); Department of Psychiatry (Low), McGill University; Departments of Anesthesiology and Medicine (Carrier), Critical Care Division, University of Montreal Hospital; Department of Pediatrics (Luu), Sainte-Justine Hospital Research Centre, University of Montreal, Montréal, Que
| | - Aimina Ayoub
- University of Montreal Hospital Research Centre (Auger, Carrier, Ayoub), School of Public Health; Institut national de santé publique du Québec (Auger, Ayoub); Department of Psychiatry (Low), McGill University; Departments of Anesthesiology and Medicine (Carrier), Critical Care Division, University of Montreal Hospital; Department of Pediatrics (Luu), Sainte-Justine Hospital Research Centre, University of Montreal, Montréal, Que
| | - Thuy Mai Luu
- University of Montreal Hospital Research Centre (Auger, Carrier, Ayoub), School of Public Health; Institut national de santé publique du Québec (Auger, Ayoub); Department of Psychiatry (Low), McGill University; Departments of Anesthesiology and Medicine (Carrier), Critical Care Division, University of Montreal Hospital; Department of Pediatrics (Luu), Sainte-Justine Hospital Research Centre, University of Montreal, Montréal, Que
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Shan F, MacVicar S, Allegaert K, Offringa M, Jansson LM, Simpson S, Moulsdale W, Kelly LE. Outcome reporting in neonates experiencing withdrawal following opioid exposure in pregnancy: a systematic review. Trials 2020; 21:262. [PMID: 32164782 PMCID: PMC7069160 DOI: 10.1186/s13063-020-4183-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/19/2020] [Indexed: 12/20/2022] Open
Abstract
Background Neonatal withdrawal secondary to in utero opioid exposure is a growing global concern stressing the psychosocial well-being of affected families and scarce hospital resources. In the ongoing search for the most effective treatment, randomized controlled trials are indispensable. Consistent outcome selection and measurement across randomized controlled trials enables synthesis of results, fostering the translation of research into practice. Currently, there is no core outcome set to standardize outcome selection, definition and reporting. This study identifies the outcomes currently reported in the literature for neonates experiencing withdrawal following opioid exposure during pregnancy. Methods A comprehensive literature search of MEDLINE, EMBASE and Cochrane Central was conducted to identify all primary research studies (randomized controlled trials, clinical trials, case-controlled studies, uncontrolled trials, observational cohort studies, clinical practice guidelines and case reports) reporting outcomes for interventions used to manage neonatal abstinence syndrome between July 2007 and July 2017. All “primary” and “secondary” neonatal outcomes were extracted by two independent reviewers and were assigned to one of OMERACT’s core areas of “pathophysiological manifestation”, “life impact”, “resource use”, “adverse events”, or “death”. Results Forty-seven primary research articles reporting 107 “primary” and 127 “secondary” outcomes were included. The most frequently reported outcomes were “duration of pharmacotherapy” (68% of studies, N = 32), “duration of hospital stay” (66% of studies, N = 31) and “withdrawal symptoms” (51% of studies, N = 24). The discrepancy between the number of times an outcome was reported and the number of articles was secondary to the use of composite outcomes. Frequently reported outcomes had heterogeneous definitions or were not defined by the study and were measured at different times. Outcomes reported in the literature to date were mainly assigned to the core areas “pathophysiologic manifestations” or “resource use”. No articles reported included parent or former patient involvement in outcome selections. Conclusions Inconsistent selection and definition of primary and secondary outcomes exists in the present literature of pharmacologic and nonpharmacologic interventions for managing opioid withdrawal in neonates. No studies involved parents in the process of outcome selection. These findings hinder evidence synthesis to generate clinically meaningful practice guidelines. The development of a specific core outcome set is imperative.
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Affiliation(s)
- Flora Shan
- Department of Pediatric and Child Health, University of Manitoba, 405 Chown, 753 McDermot Ave., Winnipeg, MB, R3E0T6, Canada
| | - Sonya MacVicar
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Karel Allegaert
- Department of Development and Regeneration, and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Clinical Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - Martin Offringa
- Department of Paediatrics, University of Toronto, Child Health Evaluative Services, The Hospital of Sick Children, Toronto, Canada
| | - Lauren M Jansson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Simpson
- Special Care Nursery, Women's and Infants' Program, St. Joseph's Healthcare, Hamilton, Canada
| | - Wendy Moulsdale
- Dan Centre for Women and Babies, Neonatal Intensive Care Unit, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Lauren E Kelly
- Department of Pediatric and Child Health, University of Manitoba, 405 Chown, 753 McDermot Ave., Winnipeg, MB, R3E0T6, Canada. .,Clinical Trials Platform, the George and Fay Yee Centre for Healthcare innovation, Winnipeg, Canada.
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125
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Frazier LM, Bobby LE, Gawronski KM. Emerging therapies for the treatment of neonatal abstinence syndrome. J Matern Fetal Neonatal Med 2020; 35:987-995. [PMID: 32146833 DOI: 10.1080/14767058.2020.1733522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: To examine the evidence for emerging treatment options, buprenorphine or clonidine, as monotherapy for the treatment of neonatal abstinence syndrome (NAS) against standards of care, morphine or methadone.Data sources: A PubMed literature search from 1946 to 2019 was performed using the terms NAS, neonatal withdrawal, buprenorphine and NAS, clonidine and NAS, morphine and NAS, methadone and NAS, opioids and pregnancy, opioids and NAS, prenatal exposure and opioids.Study selection and data extraction: Study evaluation was limited to English-language studies conducted in humans. Articles were eliminated if subjects did not have a formal diagnosis of NAS. Additionally, studies were eliminated if neonates received diluted tincture of opium. Additional references were identified from a manual citation review.Relevance to patient care and clinical practice: Eight articles were evaluated. Five articles compared buprenorphine to either morphine or methadone. Buprenorphine was found to decrease length of NAS treatment an average of 9.2 days and decrease hospital length of stay (LOS) an average of 8.2 days. Three articles evaluated the use of clonidine for NAS, two as an adjunct to morphine and one as monotherapy. Adjunctive clonidine plus morphine versus phenobarbital plus morphine both significantly reduced the total morphine treatment duration; however, patients remained on adjunctive phenobarbital significantly longer than clonidine. As monotherapy, clonidine was found to decrease NAS treatment an average of 11 days and decrease overall LOS an average of six days compared to morphine treatment.Conclusion: Treatment with buprenorphine or clonidine has shown favorable effects by reducing length of NAS treatment and LOS. These emerging therapies may be as effective as morphine or methadone for NAS, in combination with nonpharmacologic strategies. Long-term follow-up is needed.
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Affiliation(s)
- Lexus M Frazier
- School of Pharmacy, Lake Erie College of Osteopathic Medicine, Erie, PA, USA
| | - Lauren E Bobby
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Kristen M Gawronski
- School of Pharmacy, Lake Erie College of Osteopathic Medicine, Erie, PA, USA
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126
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Miller JS, Anderson JG, Erwin PC, Davis SK, Lindley LC. The Effects of Neonatal Abstinence Syndrome on Language Delay from Birth to 10 Years. J Pediatr Nurs 2020; 51:67-74. [PMID: 31923742 DOI: 10.1016/j.pedn.2019.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To examine the longitudinal effects of a history of neonatal abstinence syndrome (NAS) on language development over the first 10 years of life. DESIGN AND METHODS This study used a retrospective, longitudinal design. The data were analyzed using generalized linear mixed models (GLMM) to examine the effects of NAS on language delay over time while controlling for demographic, prenatal, and household factors. RESULTS There was a significant difference in the pattern of language delays over time between the NAS and non-NAS groups. At the age of 5 (est: -1.788, p < .001), children with a history of NAS had a decreased log odds of developing language delays than those without NAS. Conversely, compared with age 1, at the age of 10 (est: 1.098 p < .001), children with a history of NAS had an increased log odds of developing language delays than those without NAS. CONCLUSIONS Children with a history of NAS had significantly different rates of language delays over time. Children with a history of NAS had significantly higher rates of language delays at 10 years than children without NAS. PRACTICE IMPLICATIONS There is a need to increase developmental surveillance, along with referrals for specialized services, for children with a history of NAS through middle childhood.
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Affiliation(s)
- Jennifer Shearer Miller
- College of Nursing, University of Tennessee, Knoxville, Knoxville, TN, United States of America.
| | - Joel G Anderson
- College of Nursing, University of Tennessee, Knoxville, Knoxville, TN, United States of America.
| | - Paul Campbell Erwin
- School of Public Health, The University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Sharon K Davis
- College of Nursing, University of Tennessee, Knoxville, Knoxville, TN, United States of America.
| | - Lisa C Lindley
- College of Nursing, University of Tennessee, Knoxville, Knoxville, TN, United States of America.
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127
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The Parental Experience of Newborns With Neonatal Abstinence Syndrome Across Inpatient Care Settings: A Qualitative Study. J Addict Med 2020; 14:e183-e187. [DOI: 10.1097/adm.0000000000000624] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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128
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Jantzie LL, Maxwell JR, Newville JC, Yellowhair TR, Kitase Y, Madurai N, Ramachandra S, Bakhireva LN, Northington FJ, Gerner G, Tekes A, Milio LA, Brigman JL, Robinson S, Allan A. Prenatal opioid exposure: The next neonatal neuroinflammatory disease. Brain Behav Immun 2020; 84:45-58. [PMID: 31765790 PMCID: PMC7010550 DOI: 10.1016/j.bbi.2019.11.007] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/29/2019] [Accepted: 11/17/2019] [Indexed: 01/19/2023] Open
Abstract
The rates of opioid use disorder during pregnancy have more than quadrupled in the last decade, resulting in numerous infants suffering exposure to opioids during the perinatal period, a critical period of central nervous system (CNS) development. Despite increasing use, the characterization and definition of the molecular and cellular mechanisms of the long-term neurodevelopmental impacts of opioid exposure commencing in utero remains incomplete. Thus, in consideration of the looming public health crisis stemming from the multitude of infants with prenatal opioid exposure entering school age, we undertook an investigation of the effects of perinatal methadone exposure in a novel preclinical model. Specifically, we examined the effects of opioids on the developing brain to elucidate mechanisms of putative neural cell injury, to identify diagnostic biomarkers and to guide clinical studies of outcome and follow-up. We hypothesized that methadone would induce a pronounced inflammatory profile in both dams and their pups, and be associated with immune system dysfunction, sustained CNS injury, and altered cognition and executive function into adulthood. This investigation was conducted using a combination of cellular, molecular, biochemical, and clinically translatable biomarker, imaging and cognitive assessment platforms. Data reveal that perinatal methadone exposure increases inflammatory cytokines in the neonatal peripheral circulation, and reprograms and primes the immune system through sustained peripheral immune hyperreactivity. In the brain, perinatal methadone exposure not only increases chemokines and cytokines throughout a crucial developmental period, but also alters microglia morphology consistent with activation, and upregulates TLR4 and MyD88 mRNA. This increase in neuroinflammation coincides with reduced myelin basic protein and altered neurofilament expression, as well as reduced structural coherence and significantly decreased fractional anisotropy on diffusion tensor imaging. In addition to this microstructural brain injury, adult rats exposed to methadone in the perinatal period have significant impairment in associative learning and executive control as assessed using touchscreen technology. Collectively, these data reveal a distinct systemic and neuroinflammatory signature associated with prenatal methadone exposure, suggestive of an altered CNS microenvironment, dysregulated developmental homeostasis, complex concurrent neural injury, and imaging and cognitive findings consistent with clinical literature. Further investigation is required to define appropriate therapies targeted at the neural injury and improve the long-term outcomes for this exceedingly vulnerable patient population.
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Affiliation(s)
- Lauren L. Jantzie
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Neurology, Kennedy Krieger Institute, Baltimore, MD.,Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.,Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM.,Correspondence: Lauren L. Jantzie, PhD, Johns Hopkins University, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, 600 N. Wolfe Street, CMSC Building Room 6-104A, Baltimore, MD 21287,
| | - Jessie R. Maxwell
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.,Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
| | - Jessie C. Newville
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.,Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
| | - Tracylyn R. Yellowhair
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yuma Kitase
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nethra Madurai
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sindhu Ramachandra
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ludmila N. Bakhireva
- Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM
| | | | - Gwendolyn Gerner
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aylin Tekes
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lorraine A. Milio
- Department of Obstetrics & Gynecology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan L. Brigman
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
| | - Shenandoah Robinson
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrea Allan
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
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Ramphul K, Mejias SG, Joynauth J. An Update on the Burden of Neonatal Abstinence Syndrome in the United States. Hosp Pediatr 2020; 10:181-184. [PMID: 31932280 DOI: 10.1542/hpeds.2019-0221] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To provide an estimate on the most recent burden of neonatal abstinence syndrome (NAS) in the United States. METHODS The 2016 Kids' Inpatient Database, provided by the Healthcare Cost and Utilization Project and Agency for Healthcare Research and Quality and its partners, was used to identify patients with NAS in the United States. The data consisted of pediatric admissions from 4200 US hospitals recorded between January 1, 2016, and December 31, 2016. Data were converted to weighted form to project a national estimate on the possible number of neonates affected by NAS. Differences in sex, race, location, household income, primary payer form, length of stay, and total charges were studied. RESULTS The sample contained 32 128 patients with NAS (0.8%), among whom 17 164 (53.5%) were boys and 14 935 (46.5%) were girls (P < .001); 23 027 (80.4%) were white (P < .001), and 13 583 (42.3%) were from the southern parts of the United States (P < .001). Medicaid covered 83.8% of patients, and 40.2% had an income within the first quartile of national averages (P < .001). The overall mean and median length of stay were 16.45 and 12.00 days, respectively, and the mean and median total charges were calculated as $79 937.75 and $38 537.00, respectively. The total charges of NAS were $2 549 098 822. CONCLUSIONS The incidence of NAS is on a constant rise; the number of cases rose from 21 732 in 2012 to 32 128 in 2016. Hospital charges have also tripled over the last 7 years to $2.5 billion in 2016.
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Affiliation(s)
- Kamleshun Ramphul
- Department of Pediatrics, School of Medicine, Shanghai Jiao Tong University and Shanghai Xin Hua Hospital, Shanghai, China;
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130
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Abstract
Opioid use and abuse have skyrocketed in the United States over the last decade. As a result, we have seen a substantial increase in neonates who are exposed to opioids in-utero. Anywhere from 55% to 94% of infants exposed to opioids will experience withdrawal, known as neonatal abstinence syndrome (NAS), and will require management of their symptoms in the hospital. It is important to know what to look for in an infant who is experiencing NAS, how to determine if treatment is needed and what type of treatment is indicated, and how to prepare the infant for discharge once they are stable. Unfortunately, there are no standardized care plans in place for the management of this population. Although assessment tools such as the Finnegan scoring systems are available, they are not validated and can be cumbersome and difficult to administer. Other methods of assessment are being studied and may prove to be more useful in the clinical setting of neonatal withdrawal. Neither nonpharmacologic nor pharmacologic interventions are standardized, with individual institutions determining their plan of care. Development of more standardized care could significantly improve the management of these patients. [Pediatr Ann. 2020;49(1):e3-e7.].
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Ward P, Moss HG, Brown TR, Kalivas P, Jenkins DD. N-acetylcysteine mitigates acute opioid withdrawal behaviors and CNS oxidative stress in neonatal rats. Pediatr Res 2020; 88:77-84. [PMID: 31935745 PMCID: PMC7326708 DOI: 10.1038/s41390-019-0728-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 11/04/2019] [Accepted: 11/21/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) is a significant problem. Opioid withdrawal induces oxidative stress and disrupts glutamate and glutathione homeostasis. We hypothesized that N-acetylcysteine (NAC) administered during acute opioid withdrawal in neonatal rats would decrease withdrawal behaviors and normalize CNS glutathione and glutamate. METHODS Osmotic minipumps with methadone (opioid dependent, OD) and saline (Sham) were implanted into Sprague Dawley dams 7 days prior to delivery. Pups were randomized to receive either naloxone plus saline or NAC (50-100 mg/kg), administered on postnatal day (PND) 7. We performed MR spectroscopy on PND6-7 before, 30 min, and 120 min after withdrawal. On PND7, we assessed withdrawal behaviors for 90 min after naloxone administration and summed scores during peak withdrawal period. RESULTS Mean summed behavioral scores were significantly different between groups (χ2 (2) = 10.49, p = 0.005) but not different between NAC/NAL/OD and Sham (p = 0.14): SAL/NAL/OD = 17.2 ± 4.2 (n = 10); NAC/NAL/OD = 11.3 ± 5.6 (n = 9); Sham = 6.5 ± 0.6 (n = 4). SAL/NAL/OD pups had decreased glutathione at 120 min (p = 0.01), while NAC/NAL/OD pups maintained pre-withdrawal glutathione (p = 0.26). CONCLUSION In antenatal OD, NAC maintains CNS glutathione and mitigates acute opioid withdrawal in neonatal rats. This is the first study to demonstrate acute opioid withdrawal neurochemical changes in vivo in neonatal OD. NAC is a potential novel treatment for NAS.
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Affiliation(s)
- Price Ward
- 0000 0001 2189 3475grid.259828.cDepartment of Pediatrics, Medical University of South Carolina, Charleston, SC USA
| | - Hunter G. Moss
- 0000 0001 2189 3475grid.259828.cDepartment of Neuroscience, Medical University of South Carolina, Charleston, SC USA
| | - Truman R. Brown
- 0000 0001 2189 3475grid.259828.cDepartment of Radiology, Medical University of South Carolina, Charleston, SC USA
| | - Peter Kalivas
- 0000 0001 2189 3475grid.259828.cDepartment of Neuroscience, Medical University of South Carolina, Charleston, SC USA
| | - Dorothea D. Jenkins
- 0000 0001 2189 3475grid.259828.cDepartment of Pediatrics, Medical University of South Carolina, Charleston, SC USA
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132
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Burduli E, Smith CL, Tham P, Shogan M, Johnson RK, McPherson SM. Development and application of a primer and reference assessment tool for neonatal abstinence syndrome: A phase I pilot study. Contemp Clin Trials Commun 2019; 17:100494. [PMID: 31867467 PMCID: PMC6906735 DOI: 10.1016/j.conctc.2019.100494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 11/04/2019] [Accepted: 11/17/2019] [Indexed: 11/01/2022] Open
Abstract
Background Despite evidence for the efficacy of strict neonatal abstinence syndrome (NAS) treatment protocols, no national standardized education, diagnosis or treatment strategy is available. Objectives To describe the development and preliminary usability of an electronic bedside primer and decision support tool for medical providers, with embedded, interactive education and reference modules. Methods A panel of NAS experts established a standard operating procedure for the best practices of NAS management and developed an interactive mobile primer and reference and assessment tool to assess NAS with a curriculum and decision support system. We tested the feasibility and usability of this tool with n = 8 users, including registered nurses, last-year undergraduate nursing students and neonatal physicians. Results Participants rated the usability of the modules positively, with an average rating of 4.5 (scale of "1 = Strongly disagree" to "5 = Strongly agree"). Participants appreciated the ability to score the infant at the bedside using real time electronic entry. Seven users noted that the electronic device entry would be as accurate as paper or computer-based Electronic Medical Records entry and one user indicated it would potentially be more accurate during post-usability interviews. Users recommended improvements to the curriculum, including increasing detail of definitions and adding videos for additional NAS signs. Conclusion The assessment tool appears to be acceptable and usable by potential users. The strong ratings across users provides support for further testing whether its acceptability and usability remain high in a hospital setting, while assessing the impact on clinical outcomes such as newborn hospital length of stay.
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Affiliation(s)
- Ekaterina Burduli
- College of Nursing, Washington State University, Spokane, WA, 99210-1495, USA.,Analytics and PsychoPharmacology Laboratory (APPL) and the Program of Excellence in Addictions Research (PEAR), Washington State University, Spokane, WA, 99210-1495, USA
| | - Crystal Lederhos Smith
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, 99210-1495, USA.,Analytics and PsychoPharmacology Laboratory (APPL) and the Program of Excellence in Addictions Research (PEAR), Washington State University, Spokane, WA, 99210-1495, USA
| | - Phoebe Tham
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, 99210-1495, USA.,Analytics and PsychoPharmacology Laboratory (APPL) and the Program of Excellence in Addictions Research (PEAR), Washington State University, Spokane, WA, 99210-1495, USA
| | - Maureen Shogan
- College of Nursing, Washington State University, Spokane, WA, 99210-1495, USA.,Ringful Health, LLC, Spokane, WA, 99210, USA
| | | | - Sterling M McPherson
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, 99210-1495, USA.,Analytics and PsychoPharmacology Laboratory (APPL) and the Program of Excellence in Addictions Research (PEAR), Washington State University, Spokane, WA, 99210-1495, USA
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133
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Caritis SN, Panigrahy A. Opioids affect the fetal brain: reframing the detoxification debate. Am J Obstet Gynecol 2019; 221:602-608. [PMID: 31323217 DOI: 10.1016/j.ajog.2019.07.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/26/2019] [Accepted: 07/12/2019] [Indexed: 10/26/2022]
Abstract
Medication-assisted treatment is recommended for individuals with an opioid use disorder, including pregnant women. Medication-assisted treatment during pregnancy provides benefits to the mother and fetus, including better pregnancy outcomes, reduced illicit drug use, and improved prenatal care. An alternative approach, medically supervised withdrawal (detoxification), has, in recent reports, demonstrated a low risk of fetal death and low rates of relapse and neonatal abstinence syndrome. The rates of relapse and neonatal abstinence syndrome are questioned by many who view medically supervised withdrawal as unacceptable based on the concern for the potential adverse consequences of relapse to mother and baby. The impact of opioids on the fetal brain have not been integrated into this debate. Studies in animals and human brain tissues demonstrate opioid receptors in neurons, astroglia, and oligodendrocytes. Age-specific normative data from infants, children, and adults have facilitated investigation of the impact of opioids on the human brain in vivo. Collectively, these studies in animals, human neural tissue, adult brains, and the brains of children and newborns demonstrate that opioids adversely affect the human brain, primarily the developing oligodendrocyte and the processes of myelinization (white matter microstructure), connectivity between parts of the brain, and the size of multiple brain regions, including the basal ganglia, thalamus, and cerebellar white matter. These in vivo studies across the human lifespan suggest vulnerability of specific fronto-temporal-limbic and frontal-subcortical (basal ganglia and cerebellum) pathways that are also likely vulnerable in the human fetal brain. The long-term impact of these reproducible changes in the fetal brain in vivo is unclear, but the possibility of lasting injury has been suggested. In light of the recent data on medically supervised withdrawal and the emerging evidence suggesting adverse effects of opioids on the developing fetal brain, a new paradigm of care is needed that includes the preferred option of medication-assisted treatment but also the option of medically supervised opioid withdrawal for a select group of women. Both these treatment options should offer mental health and social services support throughout pregnancy. More research on both opioid exposure on the developing human brain and the impact of medically supervised withdrawal is required to identify appropriate candidates, optimal dose reduction regimens, and gestational age timing for initiating medically supervised withdrawal.
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Abstract
BACKGROUND The opioid epidemic in the United States has reached unprecedented proportions with far-reaching impacts on the most vulnerable population. The number of neonates born addicted to opioids has grown exponentially over the last several decades, leading to increased neonatal intensive care unit admissions and rising healthcare costs. Recent studies have yielded mixed results regarding which medication is most effective at relieving the symptoms of opioid withdrawal and reducing the weaning timeframe for babies with neonatal abstinence syndrome (NAS). PURPOSE To explore and compare the effectiveness of morphine versus methadone in the treatment for NAS using a standardized protocol. METHOD A literature search of PubMed and CINAHL was performed. The search yielded 10 quantitative studies that were analyzed for potential practice changes. CONCLUSION Based on current literature, following a standardized, stringent weaning protocol is more beneficial than the pharmacologic agent used. Studies reveal shorter weaning times and hospital stays in almost every group that followed rigid guidelines. IMPLICATION FOR RESEARCH Although current studies are promising for the desired outcome, more research is needed to develop appropriate protocol-based weaning regimens for management of NAS. IMPLICATION FOR PRACTICE As the occurrence of NAS continues to rise, its management must vigorously meet the challenges of the diagnosis. Institutions should reevaluate their current protocols based on reassuring data showing that stringent guidelines using morphine or methadone can improve clinical outcomes, reduce hospital length, and lower healthcare costs.
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135
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Singleton R, Slaunwhite A, Herrick M, Hirschfeld M, Brunner L, Hallas C, Truit S, Hanson S, Young M, Rider E. Research and policy priorities for addressing prenatal exposure to opioids in Alaska. Int J Circumpolar Health 2019; 78:1599275. [PMID: 31020919 PMCID: PMC6493296 DOI: 10.1080/22423982.2019.1599275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/24/2019] [Accepted: 03/15/2019] [Indexed: 12/18/2022] Open
Abstract
The current opioid crisis in Alaska and the USA will negatively affect the health and wellbeing of future generations. The increasing number of infants born with neonatal opioid withdrawal syndrome (NOWS) has had a profound impact on families, health care providers and the child welfare system. This manuscript summarises the main themes of a Symposium held in Anchorage, Alaska with health care providers, researchers, elders and public health officials that focused on identifying emerging challenges, trends and potential solutions to address the increasing number of infants and children affected by maternal opioid use. Five areas of importance for research and policy development that would direct improvement in the care of infants with NOWS in Alaska are outlined with the goal of supporting a research agenda on opioid misuse and child health across the circumpolar north. Abbreviations: NOWS - neonatal opioid withdrawal syndrome; NAS - neonatal abstinence syndrome; MAT - medication-assisted treatment; NICU - neonatal intensive care unit; OATs - opioid agonist treatments; OCS - office of children's services; ANTHC - Alaska Native Tribal Health Consortium; OUD - opioid use disorder; SBIRT - screening, brief intervention and referral to treatment; ISPCTN - IDeA States Pediatric Clinical Trials Network; NIH - National Institutes of Health; ANMC - Alaska Native Medical Center; DHSS - Department of Health and Social Services; AAPP - All Alaska Pediatric Partnership.
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Affiliation(s)
| | | | | | | | | | - Christine Hallas
- Alaska Native Tribal Health Consortium, Anchorage, AK, USA
- Southcentral Foundation, Anchorage, AK, USA
| | | | | | - Margaret Young
- Division of Public Health, Department of Health and Social Services, State of Alaska, Anchorage, AK, USA
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Clark AF. Effect of a Neonatal Abstinence Syndrome Training Program on Nurses' Confidence and Ability to Use the Finnegan Scoring Tool. Nurs Womens Health 2019; 23:485-493. [PMID: 31676285 DOI: 10.1016/j.nwh.2019.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/19/2019] [Accepted: 09/01/2019] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To study the impact of an educational training program about neonatal abstinence syndrome (NAS) on the accuracy and reliability of NAS scoring by neonatal nurses when using the Finnegan Scoring Tool (FST), as well as the impact of training on nurses' confidence when using the FST. DESIGN Pilot project based on the Plan-Do-Study-Act framework with a pretest-posttest design. SETTING/LOCAL PROBLEM Although nurses at this agency receive training on the FST as part of their unit orientation education, there is not currently a program for assessing their confidence and accuracy when using this tool over time. PARTICIPANTS A convenience sample of registered nurses from the mother-baby (n = 11), NICU (n = 5), and pediatrics (n = 1) units. INTERVENTION/MEASUREMENTS Nurses watched a video of a neonate, used the FST to score the neonate's withdrawal symptoms, and completed a rating of their self-confidence when using the tool before and after an educational training session and at a 2- to 4-week follow-up session. RESULTS Participants improved to at least 90% interobserver reliability from the pretraining (64.7%) to posttraining (94.1%) assessments. No participants maintained 90% at follow-up. There appears to be a correlation between years of neonatal experience with tool confidence at pretraining (r = 0.52, N = 17, p < .04), posttraining (r = 0.52, N = 17, p < .03), and follow-up (r = 0.56, N = 17, p < .02) assessments. Pretraining reliability had a positive correlation to follow-up reliability (r = 0.51, p < .04). There was a statistically significant increase in confidence from before the training (mean = 2.06, standard deviation = 0.56) to after (mean = 2.47, standard deviation = .51; t[16] = -3.3, p < .004 [two-tailed]). Although participants reported feeling confident when using the scoring tool, they did not always accurately score symptoms. Participants reported positive buy-in and the need for additional training. CONCLUSION Advanced training in NAS and the FST may help nurses improve NAS symptom detection and contribute to better neonatal health outcomes.
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Guttmann A, Blackburn R, Amartey A, Zhou L, Wijlaars L, Saunders N, Harron K, Chiu M, Gilbert R. Long-term mortality in mothers of infants with neonatal abstinence syndrome: A population-based parallel-cohort study in England and Ontario, Canada. PLoS Med 2019; 16:e1002974. [PMID: 31770382 PMCID: PMC6879118 DOI: 10.1371/journal.pmed.1002974] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/21/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Opioid addiction is a major public health threat to healthy life expectancy; however, little is known of long-term mortality for mothers with opioid use in pregnancy. Pregnancy and delivery care are opportunities to improve access to addiction and supportive services. Treating neonatal abstinence syndrome (NAS) as a marker of opioid use during pregnancy, this study reports long-term maternal mortality among mothers with a birth affected by NAS in relation to that of mothers without a NAS-affected birth in 2 high-prevalence jurisdictions, England and Ontario, Canada. METHODS AND FINDINGS We conducted a population-based study using linked administrative health data to develop parallel cohorts of mother-infant dyads in England and Ontario between 2002 and 2012. The study population comprised 13,577 and 4,966 mothers of infants with NAS and 4,205,675 and 929,985 control mothers in England and Ontario, respectively. Death records captured all-cause maternal mortality after delivery through March 31, 2016, and cause-specific maternal mortality to December 31, 2014. The primary exposure was a live birth of an infant with NAS, and the main outcome was all deaths among mothers following their date of delivery. We modelled the association between NAS and all-cause maternal mortality using Cox regression, and the cumulative incidence of cause-specific mortality within a competing risks framework. All-cause mortality rates, 10-year cumulative incidence risk of death, and crude and age-adjusted hazard ratios were calculated. Estimated crude 10-year mortality based on Kaplan-Meier curves in mothers of infants with NAS was 5.1% (95% CI 4.7%-5.6%) in England and 4.6% (95% CI 3.8%-5.5%) in Ontario versus 0.4% (95% CI 0.41%-0.42%) in England and 0.4% (95% CI 0.38%-0.41%) in Ontario for controls (p < 0.001 for all comparisons). Survival curves showed no clear inflection point or period of heightened risk. The crude hazard ratio for all-cause mortality was 12.1 (95% 11.1-13.2; p < 0.001) in England and 11.4 (9.7-13.4; p < 0.001) in Ontario; age adjustment did not reduce the hazard ratios. The cumulative incidence of death was higher among NAS mothers than controls for almost all causes of death. The majority of deaths were by avoidable causes, defined as those that are preventable, amenable to care, or both. Limitations included lack of direct measures of maternal opioid use, other substance misuse, and treatments or supports received. CONCLUSIONS In this study, we found that approximately 1 in 20 mothers of infants with NAS died within 10 years of delivery in both England and Canada-a mortality risk 11-12 times higher than for control mothers. Risk of death was not limited to the early postpartum period targeted by most public health programs. Policy responses to the current opioid epidemic require effective strategies for long-term support to improve the health and welfare of opioid-using mothers and their children.
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Affiliation(s)
- Astrid Guttmann
- ICES, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ruth Blackburn
- UCL Institute of Health Informatics, London, United Kingdom
| | | | | | - Linda Wijlaars
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Natasha Saunders
- ICES, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Katie Harron
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Maria Chiu
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ruth Gilbert
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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138
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Premkumar A, Grobman WA, Terplan M, Miller ES. Methadone, Buprenorphine, or Detoxification for Management of Perinatal Opioid Use Disorder: A Cost-Effectiveness Analysis. Obstet Gynecol 2019; 134:921-931. [PMID: 31599845 PMCID: PMC6870188 DOI: 10.1097/aog.0000000000003503] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To estimate whether methadone, buprenorphine, or detoxification treatment is the most cost-effective approach to the management of opioid use disorder (OUD) during pregnancy. METHODS We created a decision analytic model that compared the cost effectiveness (eg, the marginal cost of the strategy in U.S. dollars divided by the marginal effectiveness of the strategy, measured in quality-adjusted life-years [QALYs]) of initiation of methadone, buprenorphine, or detoxification in treatment of OUD during pregnancy. Probabilities, costs, and utilities were estimated from the existing literature. Incremental cost-effective ratios for each strategy were calculated, and a ratio of $100,000 per QALY was used to define cost effectiveness. One-way sensitivity analyses and a Monte Carlo probabilistic sensitivity analysis were performed. RESULTS Under base assumptions, initiation of buprenorphine was more effective at a lower cost than either methadone or detoxification and thus was the dominant strategy. Buprenorphine was no longer cost effective if the cost of methadone was 8% less than the base-case estimate ($1,646/month) or if the overall costs of detoxification were 121% less than the base-case estimate for the detoxification cost multiplier, which was used to increase the values of both inpatient and outpatient management of detoxification by a factor of 2. Monte Carlo analyses revealed that buprenorphine was the cost-effective strategy in 70.5% of the simulations. Direct comparison of buprenorphine with methadone demonstrated that buprenorphine was below the incremental cost-effective ratio in 95.1% of simulations; direct comparison between buprenorphine and detoxification demonstrated that buprenorphine was below the incremental cost-effective ratio in 45% of simulations. CONCLUSION Under most circumstances, we estimate that buprenorphine is the cost-effective strategy when compared with either methadone or detoxification as treatment for OUD during pregnancy. Nonetheless, the fact that buprenorphine was not the cost-effective strategy in almost one out of three of simulations suggests that the robustness of our model may be limited and that further evaluation of the cost-effective approach to the management of OUD during pregnancy is needed.
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Affiliation(s)
- Ashish Premkumar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - William A. Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Mishka Terplan
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Virginia Commonwealth School of Medicine, Richmond, VA USA
| | - Emily S. Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
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Trying to Do What Is Best: A Qualitative Study of Maternal-Infant Bonding and Neonatal Abstinence Syndrome. Adv Neonatal Care 2019; 19:E3-E15. [PMID: 31166199 DOI: 10.1097/anc.0000000000000616] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The maternal experience of caring for and bonding with infants affected by neonatal abstinence syndrome (NAS) has not been adequately characterized. PURPOSE This study was designed to describe mothers' experiences of, supports for, and barriers to bonding with infants with NAS. METHODS Semistructured interviews were coded using computer-assisted thematic content analysis. A code co-occurrence model was used to visualize the relationships between themes. RESULTS Thirteen mothers of infants with NAS participated. Trying to Do What Is Best emerged as the overarching theme with which several subthemes co-occurred. Subthemes that captured mothers loving their infants and bonding, feeling supported by the infants' fathers, feeling supported in the community, and receiving information from hospital staff were associated with mothers' trying to do what is best. Barriers to trying to do what is best included feeling unsupported in the community, guilt about taking medications or substances during pregnancy, feeling judged, and infant withdrawal. IMPLICATIONS FOR PRACTICE Specific implications for practice may be derived from the mothers' criticisms of NAS assessment tools. Mothers highlighted the value of reassurance and education from providers and the uniquely nonjudgmental support received from peers and male coparents. IMPLICATIONS FOR RESEARCH There is a lack of information about maternal-infant bonding in dyads affected by NAS and factors that contribute to parental loss of custody. Qualitative, quantitative, and mixed-methods studies in diverse populations might help researchers better understand the long-term outcomes of NAS and develop interventions that decrease family separation.
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140
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Treating infants with neonatal abstinence syndrome: an examination of three protocols. J Perinatol 2019; 39:1377-1383. [PMID: 31383946 DOI: 10.1038/s41372-019-0450-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 06/06/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Describe the characteristics of infants with NAS and determine if treatment outcomes varied between three protocols. STUDY DESIGN Based on medical record data, infant treatment for NAS-related withdrawal reflected one of three protocols: (1) No rescue dose (n = 836, 52.7%): Prescriber ordered initiation and escalation doses and determined when infants were eligible for weaning, (2) Rescue dose (n = 233, 14.7%): No rescue dose with the addition of a prescriber-ordered rescue dose, (3) Rescue dose by order set (n = 516, 32.6%): Rescue dose with addition of nurse-assisted order of morphine during escalation. RESULTS The no rescue dose group had longer length of stay, days to wean, and inpatient days, and greater initial morphine dose than the two rescue dose groups (p < 0.001). Treatment outcomes between the two rescue dose protocols did not differ. CONCLUSIONS The benefits related to rescue dosing further inform the development of a standardized NAS treatment protocol.
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141
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Parikh A, Gopalakrishnan M, Azeem A, Booth A, El-Metwally D. Racial association and pharmacotherapy in neonatal opioid withdrawal syndrome. J Perinatol 2019; 39:1370-1376. [PMID: 31388115 DOI: 10.1038/s41372-019-0440-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/15/2019] [Accepted: 06/03/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine if racial differences are associated with Neonatal Opioid Withdrawal Syndrome (NOWS) severity. STUDY DESIGN A 10-year (2008-2017) retrospective cohort of infants ≥35 weeks gestation with prenatal exposure to opioids was included. The primary measure was the need for pharmacotherapy. Multivariable logistic regression and propensity score analysis were performed. RESULTS Among 345 infants with NOWS, 111 (32%) were black infants with 70% of them requiring pharmacotherapy as compared with 84% of white infants. Upon adjusting for significant covariates (methadone, benzodiazepine use, and gestational age), black infants were 57% less likely than whites to require pharmacotherapy (Odds ratio: 0.43, 95%CI: 0.22-0.80, p = 0.009). Similar results were observed with propensity score analysis. CONCLUSIONS Significant racial disparity observed may be secondary to genetic variations in opioid pharmacogenomics and/or extrinsic factors. Large-scale studies are warranted to include race in predictive models for early pharmacological intervention.
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Affiliation(s)
- Abhinav Parikh
- University of Maryland Medical Center, Baltimore, MD, USA.
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Ahad Azeem
- Long Island Jewish Forrest Hill Hospital, Forrest Hill, NY, 11375, USA
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Dave CV, Goodin A, Zhu Y, Winterstein A, Wang X, Alrwisan A, Hartzema A. Prevalence of Maternal‐Risk Factors Related to Neonatal Abstinence Syndrome in a Commercial Claims Database: 2011‐2015. Pharmacotherapy 2019; 39:1005-1011. [DOI: 10.1002/phar.2315] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Chintan V. Dave
- Department of Pharmaceutical Outcomes and Policy College of Pharmacy University of Florida Gainesville Florida
| | - Amie Goodin
- Department of Pharmaceutical Outcomes and Policy College of Pharmacy University of Florida Gainesville Florida
| | - Yanmin Zhu
- Department of Pharmaceutical Outcomes and Policy College of Pharmacy University of Florida Gainesville Florida
| | - Almut Winterstein
- Department of Pharmaceutical Outcomes and Policy College of Pharmacy University of Florida Gainesville Florida
| | - Xi Wang
- Department of Pharmaceutical Outcomes and Policy College of Pharmacy University of Florida Gainesville Florida
| | - Adel Alrwisan
- Department of Pharmaceutical Outcomes and Policy College of Pharmacy University of Florida Gainesville Florida
| | - Abraham Hartzema
- Department of Pharmaceutical Outcomes and Policy College of Pharmacy University of Florida Gainesville Florida
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143
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Shearer JN, Erwin PC, Davis SK, Anderson JG, Lindley LC. Implications of Tennessee's Opioid Legislation for Neonatal Abstinence Syndrome. Policy Polit Nurs Pract 2019; 20:153-162. [PMID: 31390304 DOI: 10.1177/1527154419864540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Opioid use during pregnancy is on the rise in the United States. Neonatal abstinence syndrome (NAS), also known as newborn drug withdrawal, is a public health epidemic. Between 2004 and 2014, Tennessee experienced a fivefold increase in NAS hospitalizations, from 1.5 to 8.0 per 1,000 live births. Soaring increases in the number of newborns with NAS nationwide have caught the attention of many federal and state lawmakers, especially given the unknown burdens associated with medical and social services needed by those affected over time. Tennessee opioid-related regulations and laws enacted between 2000 and 2018 were systematically reviewed and analyzed to identify each law's purpose; effects on families and individuals; pros and cons in terms of social, practical, and legal factors; and implications for nursing practice. Our findings were that Tennessee's laws are intended to decrease the number of opioids prescribed, ensure access to continued prenatal care and substance abuse management for mothers with substance use disorders, and reduce the ease of obtaining opioids. We also found that Tennessee lawmakers have enacted laws and regulations aimed at decreasing the abuse of opioids, but not reducing the incidence of NAS. As new laws are considered, it is critical that health care providers and lawmakers work together to ensure that the developed and enacted laws strike a balance between safely managing the care of both pregnant women and their newborns without producing negative outcomes.
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Affiliation(s)
| | | | - Sharon K Davis
- College of Nursing University of Tennessee, Knoxville, TN, USA
| | - Joel G Anderson
- College of Nursing University of Tennessee, Knoxville, TN, USA
| | - Lisa C Lindley
- College of Nursing University of Tennessee, Knoxville, TN, USA
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144
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Lisonkova S, Richter LL, Ting J, Muraca GM, Wen Q, Mehrabadi A, Mitchell-Foster S, Oviedo-Joekes E, Lyons J. Neonatal Abstinence Syndrome and Associated Neonatal and Maternal Mortality and Morbidity. Pediatrics 2019; 144:peds.2018-3664. [PMID: 31300529 DOI: 10.1542/peds.2018-3664] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We examined demographic characteristics and birth outcomes of infants with neonatal abstinence syndrome (NAS) and their mothers in Canada. METHODS This retrospective, population-based, descriptive cross-sectional study of mother-infant dyads included all singleton live births in Canada (excluding Quebec), from 2005-2006 to 2015-2016 (N = 2 881 789). Demographic characteristics, NAS, and neonatal and maternal morbidities were identified from delivery hospitalization data (including diagnostic codes). The main composite outcomes were maternal and neonatal mortality and/or severe morbidity, including death and potentially life-threatening conditions in the mother and the infant, respectively. Logistic regression yielded adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS The study included 10 027 mother-infant dyads with NAS. The incidence of NAS increased from 0.20% to 0.51%. Maternal mortality was 1.99 vs 0.31 per 10 000 women in the NAS group versus the comparison group (aOR = 6.53; 95% CI: 1.59 to 26.74), and maternal mortality and/or severe morbidity rates were 3.10% vs 1.35% (aOR = 2.21; 95% CI: 1.97 to 2.49). Neonatal mortality was 0.12% vs 0.19% (aOR = 0.28; 95% CI: 0.15 to 0.53), and neonatal mortality and/or severe morbidity rates were 6.36% vs 1.73% (aOR = 2.27; 95% CI: 2.06 to 2.50) among infants with NAS versus without NAS. CONCLUSIONS NAS incidence increased notably in Canada between 2005-2006 and 2015-2016. Infants with NAS had elevated severe morbidity, and their mothers had elevated mortality and severe morbidity. These results highlight the importance of implementing integrated care services to support the mother-infant dyad during childbirth and in the postpartum period.
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Affiliation(s)
- Sarka Lisonkova
- Departments of Obstetrics and Gynecology and .,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Joseph Ting
- Pediatrics, University of British Columbia and the British Columbia Women's Hospital and Health Center, Vancouver, British Columbia, Canada
| | | | - Qi Wen
- Department of Statistics and Actuarial Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Azar Mehrabadi
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Sheona Mitchell-Foster
- Departments of Obstetrics and Gynecology and.,Northern Medical Program, University of British Columbia, Prince George, British Columbia, Canada; and
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul's Hospital, Vancouver, Canada
| | - Janet Lyons
- Departments of Obstetrics and Gynecology and
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145
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Loyal J, Nguyen VN, Picagli D, Petrucelli A, O'Mara E, Grossman MR, Colson E. Postpartum Nurses' Experience Caring for Infants With Neonatal Abstinence Syndrome. Hosp Pediatr 2019; 9:601-607. [PMID: 31331933 DOI: 10.1542/hpeds.2019-0087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES In previous years, otherwise healthy infants with neonatal abstinence syndrome (NAS) in our hospital were transferred to the NICU and frequently treated with medication. Currently, infants with NAS room-in with their mothers and rarely require medication. We sought to understand the lived experience of nurses on maternity and well-newborn units caring for infants with NAS. METHODS We conducted focus groups of registered nurses on postpartum units at 2 hospitals using qualitative methodology. Themes were identified through consensus, and the focus groups were stopped when no new themes were identified. RESULTS Seventeen postpartum nurses participated in 5 focus groups. The following major themes emerged: (1) managing the expectations of parents of newborns with NAS, (2) current NAS protocol (positive aspects of rooming-in and challenges with withdrawal scoring tool), (3) inconsistencies in care and communication, (4) perceived increase in nursing workload on the postpartum unit, and (5) nurses' emotional response to the care of infants with NAS. CONCLUSIONS We highlight the perspectives of nursing staff on the well-newborn unit who were previously unaccustomed to caring for infants with NAS. With increasing numbers of infants with NAS and longer stays on the well-newborn unit, hospitals must prepare to better support staff and implement protocols that offer consistency in practice.
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Affiliation(s)
- Jaspreet Loyal
- Department of Pediatrics, Yale University, New Haven, Connecticut;
| | - Victoria N Nguyen
- Department of Pediatrics, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | | | | | | | | | - Eve Colson
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
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146
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Landau R. Post-cesarean delivery pain. Management of the opioid-dependent patient before, during and after cesarean delivery. Int J Obstet Anesth 2019; 39:105-116. [DOI: 10.1016/j.ijoa.2019.01.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 12/24/2018] [Accepted: 01/18/2019] [Indexed: 12/26/2022]
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147
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McQueen K, Taylor C, Murphy-Oikonen J. Systematic Review of Newborn Feeding Method and Outcomes Related to Neonatal Abstinence Syndrome. J Obstet Gynecol Neonatal Nurs 2019; 48:398-407. [DOI: 10.1016/j.jogn.2019.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2019] [Indexed: 12/18/2022] Open
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148
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Sanlorenzo LA, Cooper WO, Dudley JA, Stratton S, Maalouf FI, Patrick SW. Increased Severity of Neonatal Abstinence Syndrome Associated With Concomitant Antenatal Opioid and Benzodiazepine Exposure. Hosp Pediatr 2019; 9:569-575. [PMID: 31262946 DOI: 10.1542/hpeds.2018-0227] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Polysubstance use is common among opioid-using women, yet its association with pharmacotherapy for neonatal abstinence syndrome (NAS) remains unclear. We hypothesized that benzodiazepine exposure would increase risk of an infant developing pharmacologically treated NAS. METHODS We conducted a retrospective cohort study of maternal-infant dyads enrolled in Tennessee Medicaid, using individual-level data linkage of vital records and administrative (ie, outpatient, inpatient, and prescription) data from 2009 to 2011. These data underwent chart review from 2013 to 2016 to obtain clinically relevant exposure data (eg, toxicology testing). The association of antenatal exposures with pharmacologically treated NAS was evaluated by using multivariable logistic regression, controlling for maternal and infant factors and clustered by hospital. RESULTS Among 112 029 maternal-infant dyads, we confirmed 822 cases of NAS, of which 598 (72.7%) were cases of pharmacologically treated NAS. Infants who developed pharmacologically treated NAS were more likely to have been exposed to antenatal benzodiazepines compared with infants with confirmed NAS not treated pharmacologically (40.9% vs 30.8%; P = .008). In adjusted analyses, benzodiazepine exposure was associated with greater risk of developing pharmacologically treated NAS (odds ratio: 1.51; 95% confidence interval: 1.04-2.21). Alternatively, exposure to tobacco, marijuana, cocaine, gabapentin, and selective serotonin reuptake inhibitors were not associated with increased risk of developing pharmacologically treated NAS. CONCLUSIONS Among a population of infants with intrauterine polysubstance exposure, benzodiazepine exposure was an independent predictor of an infant developing pharmacologically treated NAS. Obtaining history of antenatal benzodiazepine exposure among opioid-exposed infants may allow for risk stratification and development of personalized care plans.
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Affiliation(s)
- Lauren A Sanlorenzo
- Departments of Pediatrics and .,Mildred Stahlman Division of Neonatology and.,Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and
| | - William O Cooper
- Departments of Pediatrics and.,Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and.,Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Judith A Dudley
- Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shannon Stratton
- Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Faouzi I Maalouf
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon
| | - Stephen W Patrick
- Departments of Pediatrics and.,Mildred Stahlman Division of Neonatology and.,Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and.,Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
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149
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Mathis SM, Hagemeier N, Hagaman A, Dreyzehner J, Pack RP. A Dissemination and Implementation Science Approach to the Epidemic of Opioid Use Disorder in the United States. Curr HIV/AIDS Rep 2019; 15:359-370. [PMID: 30069724 DOI: 10.1007/s11904-018-0409-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review aims to (1) conceptualize the complexity of the opioid use disorder epidemic using a conceptual model grounded in the disease continuum and corresponding levels of prevention and (2) summarize a select set of interventions for the prevention and treatment of opioid use disorder. RECENT FINDINGS Epidemiologic data indicate non-medical prescription and illicit opioid use have reached unprecedented levels, fueling an opioid use disorder epidemic in the USA. A problem of this magnitude is rooted in multiple supply- and demand-side drivers, the combined effect of which outweighs current prevention and treatment efforts. Multiple primary, secondary, and tertiary prevention interventions, both evidence-informed and evidence-based, are available to address each point along the disease continuum-non-use, initiation, dependence, addiction, and death. If interventions grounded in the best available evidence are disseminated and implemented across the disease continuum in a coordinated and collaborative manner, public health systems could be increasingly effective in responding to the epidemic.
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Affiliation(s)
- Stephanie M Mathis
- College of Public Health, East Tennessee State University, Johnson City, TN, USA
- Center for Prescription Drug Abuse Prevention and Treatment, East Tennessee State University, Johnson City, TN, USA
| | - Nicholas Hagemeier
- Center for Prescription Drug Abuse Prevention and Treatment, East Tennessee State University, Johnson City, TN, USA
- Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - Angela Hagaman
- College of Public Health, East Tennessee State University, Johnson City, TN, USA
- Center for Prescription Drug Abuse Prevention and Treatment, East Tennessee State University, Johnson City, TN, USA
| | | | - Robert P Pack
- College of Public Health, East Tennessee State University, Johnson City, TN, USA.
- Center for Prescription Drug Abuse Prevention and Treatment, East Tennessee State University, Johnson City, TN, USA.
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150
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Carlson K, Kieran K. Narratives of neonatal abstinence syndrome. Arch Psychiatr Nurs 2019; 33:275-283. [PMID: 31227080 DOI: 10.1016/j.apnu.2019.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Kelly Carlson
- McLean Hospital, Belmont, MA, United States of America.
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