Morphine vs Methadone Treatment for Infants with Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome in Infants with Prenatal Exposure to Methadone versus Buprenorphine

Neonatal abstinence syndrome (NAS) has been of increasing concern. Studies suggest that prenatal exposure to buprenorphine may be preferred to methadone in regard to neonatal withdrawal. Our aim was to determine whether the incidence and severity of NAS are different between babies prenatally exposed to methadone or buprenorphine in pregnancy. This retrospective analysis of infants ≥ 35-weeks-old exposed to methadone/buprenorphine alone or in conjunction with other substances in utero. They were divided into four groups: 1-methadone alone (Met), 2-buprenorphine alone (Bup), 3 and 4-those exposed to methadone and buprenorphine, respectively, in conjunction with other drugs (Met+ and Bup+). The frequency of NAS treatment, duration of treatment (LOT) and length of stay (LOS) were compared between groups. Of the 290 mothers, 59% were in the Met group, 18% in the Bup group, 14% in the Met or Bup and another opiate group, and 9% took methadone or buprenorphine plus various other substances. Infants born to Met/Met+ mothers had a four-times higher likelihood of developing NAS (p < 0.001). There was no difference in the LOS (p = 0.08) or LOT (p = 0.11) between groups. The buprenorphine treatment in pregnancy decreased the risk of babies developing NAS. However, once the NAS required pharmacological treatment, the type of maternal prenatal exposure did not affect the LOS or LOT.

Future Newborns with Opioid-Induced Neonatal Abstinence Syndrome (NAS) Could Be Assessed with the Genetic Addiction Risk Severity (GARS) Test and Potentially Treated Using Precision Amino-Acid Enkephalinase Inhibition Therapy (KB220) as a Frontline Modality Instead of Potent Opioids

In this nonsystematic review and opinion, including articles primarily selected from PubMed, we examine the pharmacological and nonpharmacological treatments of neonatal abstinence syndrome (NAS) in order to craft a reasonable opinion to help forge a paradigm shift in the treatment and prevention of primarily opioid-induced NAS. Newborns of individuals who use illicit and licit substances during pregnancy are at risk for withdrawal, also known as NAS. In the US, the reported prevalence of NAS has increased from 4.0 per 1000 hospital births in 2010 to 7.3 per 1000 hospital births in 2017, which is an 82% increase. The management of NAS is varied and involves a combination of nonpharmacologic and pharmacologic therapy. The preferred first-line pharmacological treatment for NAS is opioid therapy, specifically morphine, and the goal is the short-term improvement in NAS symptomatology. Nonpharmacological therapies are individualized and typically focus on general care measures, the newborn-parent/caregiver relationship, the environment, and feeding. When used appropriately, nonpharmacologic therapies can help newborns with NAS avoid or reduce the amount of pharmacologic therapy required and the length of hospitalization. In addition, genetic polymorphisms of the catechol-o-methyltransferase (COMT) and mu-opioid receptor (OPRM1) genes appear to affect the length of stay and the need for pharmacotherapy in newborns with prenatal opioid exposure. Therefore, based on this extensive literature and additional research, this team of coauthors suggests that, in the future, in addition to the current nonpharmacological therapies, patients with opioid-induced NAS should undergo genetic assessment (i.e., the genetic addiction risk severity (GARS) test), which can subsequently be used to guide DNA-directed precision amino-acid enkephalinase inhibition (KB220) therapy as a frontline modality instead of potent opioids.

Morphine versus methadone for neonatal opioid withdrawal syndrome: a randomized controlled pilot study

BACKGROUND

Neonatal Opioid Withdrawal Syndrome (NOWS) is a significant public health issue and while millions of neonates are affected each year, an optimal pharmacologic weaning protocol has yet to be demonstrated. In this study, we compare hospital length of stay (LOS) and length of treatment (LOT) for treatment of neonatal opioid withdrawal (NOWS) with morphine versus methadone.

METHODS

This was a single-site, open-label, randomized controlled pilot study conducted from October 2016-September 2018. Infants were eligible if their primary in-utero drug exposure was heroin, oral opioids, or methadone and they were born at greater than or equal to 34 weeks gestation. Infants were excluded for serious medical comorbidities and primary in-utero exposure to buprenorphine.

RESULTS

Sixty-one infants were enrolled; 30 were randomized to methadone treatment, and 31 to morphine treatment. Overall 46% of infants required treatment for NOWS. LOS and LOT for infants treated with morphine was 17.9 days and 14.7 days respectively, compared to 16.1 days and 12.8 days for babies treated with methadone (p = 0.5, p = 0.54). Infants treated with morphine received lower total morphine equivalents than those treated with methadone (9.7 vs. 33, p < 0.01). Three treated infants in the methadone group required transfer to the Neonatal Intensive Care Unit, versus no infants in the morphine group.

CONCLUSIONS

Infants treated with morphine versus methadone had no significant differences in LOS or LOT in this pilot study. Infants treated with methadone received up to 3 times the opioid based on morphine equivalents as infants treated with morphine and had more transfers to the NICU for over sedation.

CLINICAL TRIAL REGISTRATION

Morphine Versus Methadone for Opiate Exposed Infants With Neonatal Abstinence Syndrome NCT02851303 , initiated 01/08/2016.

Incidence of Neonatal Abstinence Syndrome (NAS) in Castilla y Leon (Spain)

Introduction: Neonatal Abstinence Syndrome (NAS) is considered a Public Health problem that is defined as a group of symptoms that appear in the newborn due to withdrawal from intrauterine drug exposure. Objective: The aim of this study was to analyze the incidence of NAS in Castilla y León from 2000 to 2019. Methodology: Data of NAS cases in Castilla y León from 2000 to 2019 were obtained. NAS incidence per 1000 births was calculated and the correlation among data from different provinces and years was analyzed. Results: The cumulative incidence of NAS in Castilla y León per 1000 births between 2000-2019 was 0.91‰, with great interprovincial variability. The provinces of Zamora and Palencia stand out, with high incidence rates of NAS despite their low birth rates. The temporal trend points towards a decrease in incidence from 2000 to 2019. Opioids such as methadone, cannabis, benzodiazepines and poly-drug use are the most prevalent drugs causing NAS, and it has also been observed that methadone is being replaced by cannabis as the major cause of NAS cases at the University Hospital in Salamanca in recent years. Conclusions: The incidence of NAS in Castilla y León decreased in 2004 and remained constant until 2019, but it shows great interprovincial variability. It is necessary to implement a national NAS Registry to obtain comprehensive information regarding its incidence.

Neonatal Abstinence Syndrome Practices in the United States

OBJECTIVE

To survey current practices for the treatment of neonatal abstinence syndrome (NAS) among institutions in the United States to identify changes in national practice over time.

METHODS

Previous NAS management reports were referenced in the development of our 26-question electronic survey, which was distributed in the fall of 2019 to pediatric practitioners of 2 national clinical pharmacy organizations via email list servers. Not all questions required a response and responses from incomplete surveys were included. Institution demographics and NAS management strategies, including location of care, observation period, and inpatient and outpatient pharmacotherapy, were queried.

RESULTS

Seventy respondents representing institutions from all US geographic regions participated in the survey The most commonly reported inpatient observation durations were 3 (18 of 61, 29%) and 5 (22 of 61, 36%) days. Respondents indicated that neonates were typically transferred to the NICU if pharmacologic management was required (38 of 56, 68%). According to participants, first-line agents used for NAS management were morphine (45 of 56, 80%), methadone (5 of 56, 9%), clonidine (2 of 56, 4%), and buprenorphine (2 of 56, 4%). Among respondents, only 20% (11 of 56) reported that infants may be discharged home on pharmacotherapy, including morphine (n = 6), phenobarbital (n = 3), clonidine (n = 1), and methadone (n = 1).

CONCLUSIONS

Opioids are the most commonly used first-line agents for NAS management in the United States. The primary site of NAS management is the inpatient setting, as only 20% of institutions report discharging patients on pharmacotherapy.

Multilevel factors associated with length of stay for neonatal abstinence syndrome in Florida's NICUs: 2010-2015

OBJECTIVE

To investigate potential factors influencing initial length of hospital stay (LOS) for infants with neonatal abstinence syndrome (NAS) in Florida.

METHODS

The study population included 2984 term, singleton live births in 33 Florida hospitals. We used hierarchical linear modeling to evaluate the association of community, hospital, and individual factors with LOS.

RESULTS

The average LOS of infants diagnosed with NAS varied significantly across hospitals. Individual-level factors associated with increased LOS for NAS included event year (P < 0.001), gestational age at birth (P < 0.001), maternal age (P = 0.002), maternal race and ethnicity (P < 0.001), maternal education (P = 0.032), and prenatal care adequacy (P < 0.001). Average annual hospital NAS volume (P = 0.022) was a significant hospital factor.

CONCLUSION

NAS varies widely across hospitals in Florida. In addition to focusing on treatment regimens, to reduce LOS, public health and quality improvement initiatives should identify and adopt strategies that can minimize the prevalence and impact of these contributing factors.

Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences

Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.

Opioid Treatment for Neonatal Opioid Withdrawal Syndrome: Current Challenges and Future Approaches

Chronic intrauterine exposure to psychoactive drugs often results in neonatal opioid withdrawal syndrome (NOWS). When nonpharmacologic measures are insufficient in controlling NOWS, morphine, methadone, and buprenorphine are first-line medications commonly used to treat infants with NOWS because of in utero exposure to opioids. Research suggests that buprenorphine may be the leading drug therapy used to treat NOWS when compared with morphine and methadone. Currently, there are no consensus or standardized treatment guidelines for medications prescribed for NOWS. Opioids used to treat NOWS exhibit large interpatient variability in pharmacokinetics (PK) and pharmacodynamic (PD) response in neonates. Organ systems undergo rapid maturation after birth that may alter drug disposition and exposure for any given dose during development. Data regarding the PK and PD of opioids in neonates are sparse. Pharmacometric methods such as physiologically based pharmacokinetic and population pharmacokinetic modeling can be used to explore factors predictive of some of the variability associated with the PK/PD of opioids in newborns. This review discusses the utility of pharmacometric techniques for enhancing precision dosing in infants requiring opioid treatment for NOWS. Applying these approaches may contribute to optimizing the outcome by reducing cumulative drug exposure, mitigating adverse drug effects, and reducing the burden of NOWS in neonates.

Evaluating Definitions for Neonatal Abstinence Syndrome

BACKGROUND AND OBJECTIVES

National estimates indicate that the incidence of neonatal abstinence syndrome (NAS), a postnatal opioid withdrawal syndrome, increased more than fivefold between 2004 and 2016. There is no gold standard definition for capturing NAS across clinical, research, and public health settings. Our objective was to evaluate how different definitions of NAS modify the calculated incidence when applied to a known population of opioid-exposed infants.

METHODS

Data for this retrospective cohort study were obtained from opioid-exposed infants born at Vanderbilt University Medical Center in 2018. Six commonly used clinical and surveillance definitions of opioid exposure and NAS were applied to the study population and evaluated for accuracy in assessing clinical withdrawal.

RESULTS

A total of 121 opioid-exposed infants met the criteria for inclusion in our study. The proportion of infants who met criteria for NAS varied by predefined definition, ranging from 17.4% for infants who received morphine to 52.8% for infants with the diagnostic code for opioid exposure. Twenty-eight infants (23.1%) received a clinical diagnosis of NAS by a medical provider, and 38 (34.1%) received the diagnostic code for NAS at discharge.

CONCLUSIONS

We found significant variability in the incidence of opioid exposure and NAS among a single-center population using 6 common definitions. Our findings suggest a need to develop a gold standard definition to be used across clinical, research, and public health surveillance settings.

Development and validation of the Neonatal Abstinence Syndrome Minimum Data Set (NAS-MDS): a systematic review, focus group discussion, and Delphi technique

OBJECTIVES

Neonatal abstinence syndrome (NAS) is a combination of symptoms in infants exposed to any variety of substances in utero. Information systems and registries help to collect information about these patients; however, there is always a deep gap between complete and accurate information to be collected, understood, and applied in the health care system; thus, defining a minimum data sets (MDS) as one of the primarily steps of designing a registry system is essential. The aim of this study was to develop an MDS of the registry for infants with NAS in Iran.

METHODS

This research is a descriptive cross-sectional study. In this study, three steps were carried out to develop the MDS including systematic review, Delphi technique, and focus group discussion. A systematic review was conducted in relevant databases to identify appropriate related data. In the second phase, a focus group discussion was used to classify the extracted data elements by contributing neonatologists. Finally, data elements were chosen through the decision Delphi technique in two distinct rounds. Collected data were analyzed using SPSS 22 (SPSS Inc., Chicago, IL).

RESULTS

By reviewing related papers and available NAS registries in other countries, 145 essential data elements were identified. They were classified into two main categories based on the eight experts' opinions including maternal with two sections and infant with two sections. After applying two rounds of Delphi technique, the final data elements for maternal and infant categories were 42 and 31, respectively. Thus, on completion of the survey, 73 data elements were approved.

CONCLUSION

The proposed MDS for NAS can help to store an accurate and comprehensive data, document medical records, integrate them with other information systems and registries, and communicate with other healthcare providers and healthcare centers. This MDS can contribute to the provision of high-quality care and better clinical decisions.

Neonatal abstinence syndrome management in California birth hospitals: results of a statewide survey

OBJECTIVE

Assess management of neonatal abstinence syndrome (NAS) in California hospitals to identify potential opportunities to expand the use of best practices.

STUDY DESIGN

We fielded an internet-based survey of 37 questions to medical directors or nurse managers at 145 birth hospitals in California.

RESULTS

Seventy-five participants (52%) responded. Most respondents reported having at least one written protocol for managing NAS, but gaps included protocols for pharmacologic management. Newer tools for assessing NAS severity were not commonly used. About half reported usually or always using nonpharmacologic strategies; there is scope for increasing breastfeeding when recommended, skin-to-skin care, and rooming-in.

CONCLUSIONS

We found systematic gaps in care for infants with NAS in a sample of California birth hospitals, as well as opportunities to spread best practices. Adoption of new approaches will vary across hospitals. A concerted statewide effort to facilitate such implementation has strong potential to increase access to evidence-based treatment for infants and mothers.

Neonatal Abstinence Syndrome: Review of Epidemiology, Care Models, and Current Understanding of Outcomes

The incidence of neonatal abstinence syndrome owing to prenatal opioid exposure has grown rapidly in recent decades and it disproportionately affects rural, non-white, and public insurance-dependent populations. Treatment consists of pharmacologic and nonpharmacologic interventions with wide variability in approaches across the United States. Standardizing clinical assessment, minimizing unnecessary interruptions, and prioritizing nonpharmacologic and family-centered care seems to improve hospital outcomes. Neonatal abstinence syndrome may have long-term developmental and biological effects, but understanding is limited owing in part confounding biosocial factors. Early intervention and longitudinal support of the infant and family promote better outcomes.

Comparative effectiveness of opioid replacement agents for neonatal opioid withdrawal syndrome: a systematic review and meta-analysis

OBJECTIVE(S)

To compare short-term treatment outcomes of opioid pharmacotherapy for neonatal opioid withdrawal syndrome (NOWS).

STUDY DESIGN

PubMed/MEDLINE, Embase, PsycINFO, and The Cochrane Library were searched from inception through September 30, 2018. Primary outcome was treatment duration (LOT). Secondary outcomes included hospitalization duration (LOS) and rate of adjunct drug needed (RAD).

RESULTS

Of 753 publications, 11 studies met inclusion criteria. There was no difference in LOT (WMD -1.39 [-5.79 to -3.01] days, I² 82%) or LOS (WMD -1.48 [-5.75 to -2.79] days, I² 92%) between morphine and methadone. RAD with morphine was higher (RR 1.51 [1.35-1.69], I² 0%). Buprenorphine was associated with shorter LOT (WMD 7.70 [0.88-14.53] days, I² 76%) and LOS (WMD 5.61 [-0.01 to -11.24] days, I² 60%) compared with morphine, in addition to methadone according to two cohort studies.

CONCLUSIONS

Methadone had superior primary treatment success compared with morphine. Buprenorphine was associated with the shortest overall durations of treatment and hospitalization.

Methadone versus morphine treatment outcomes in neonatal abstinence syndrome: A meta-analysis

AIM

To determine whether morphine has better outcomes for neonatal abstinence syndrome treatment than methadone.

METHODS

Studies published before 1 January 2019 were identified using the PubMed, Web of Science, Scopus, Cochrane Library and ClinicalTrials.gov databases. The Cochrane Collaboration Risk of Bias Tool was used to assess the risk of bias for randomised clinical trials. In addition, the risk of bias for non-randomised studies was evaluated by a non-randomised studies of interventions tool.

RESULTS

We identified 1020 published studies, and 5 were included in the final analysis. Results showed no significant difference in opioid treatment days (standardised mean difference (SMD) = 0.32, 95% confidence interval (CI) = -0.16, 0.80), length of hospital stay (SMD = -0.33, 95% CI = -1.21, 0.56) and duration of treatment (SMD = -0.83 95% CI = -2.09, 0.43) between morphine or methadone treatment.

CONCLUSIONS

Our meta-analysis of current evidence demonstrated that neonatal abstinence syndrome treatment with morphine was not associated with better outcomes in infants compared with methadone treatment.

Analgesia, Opioids, and Other Drug Use During Pregnancy and Neonatal Abstinence Syndrome

When opioid misuse rises in the United States, pregnant women and their neonates are affected. This article summarizes the use of Food and Drug Administration-approved products, including methadone, buprenorphine, and the combination formulation of buprenorphine and naloxone to treat adult opioid use disorder during the perinatal period. All labels include pregnancy, neonatal, and lactation information and note the accepted use of these medications during the perinatal period if the benefits outweigh the risks. A summary of the neonatal abstinence syndrome definition, its assessment tools, treatment approaches, and future genetic directions are provided.

Neonatal abstinence syndrome: a systematic review of current databases and registries

OBJECTIVES

Registries are considered as rich sources of data for determination of infants with neonatal abstinence syndrome (NAS), the improvement of provided care and research. The aims of this study were: (1) to investigate the existing studies including NAS registries, (2) to identify and extract the required data elements.

METHODS

The following electronic databases were searched: PubMed, Scopus, Web of Science, ProQuest, Embase/Medline, and Psych Info. In addition, a review of gray literature was undertaken to identify relevant studies in English covering the period from 1 January 2009 to 1 November 2018 including registries and databases. Screening of titles, abstracts, and full-texts were conducted independently by two researchers based on PRISMA guidelines. The basic registry information, scope, registry type, data source, the purpose of registry, important variables were extracted and analyzed.

RESULTS

Twenty-five articles were eligible and included in the review; they reported 37 registries and databases related to NAS at the national and state levels in 11 countries from 1876 to 2013. We proposed a NAS registry design framework based on well-known data-information-knowledge (DIK) structure due to Ackoff's DIK hierarchy has a defined role as a central model of information systems, information management, and knowledge management.

CONCLUSIONS

To the best of our knowledge, this is the first study which has systematically reviewed NAS-related registries. Since there are no international standards to develop new NAS registries, the proposed framework in this article can be beneficial. This framework is essential not only to facilitate the NAS registry design but also to help the collection of high-value clinical data necessary for the acquisition of better clinical knowledge.