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Jamali Z, Molaei-Farsangi MH, Ahmadipour H, Bahmanbijari B, Sabzevari F, Parizi ZD. Comparison of the effect of phenobarbital & levetiracetam in the treatment of neonatal abstinence syndrome (NAS) as adjuvant treatment in neonates admitted to the neonatal intensive care unit: a randomized clinical trial. BMC Pregnancy Childbirth 2024; 24:242. [PMID: 38580935 PMCID: PMC10996075 DOI: 10.1186/s12884-024-06433-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/18/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Infants who are born from mothers with substance use disorder might suffer from neonatal abstinence syndrome (NAS) and need treatment with medicines. One of these medicines is phenobarbital, which may cause side effects in long-term consumption. Alternative drugs can be used to reduce these side effects. This study seeks the comparison of the effects of phenobarbital & levetiracetam as adjuvant therapy in neonatal abstinence syndrome. METHODS This randomized clinical trial was performed in one year from May 2021 until May 2022. The neonates who were born from mothers with substance use disorder and had neonatal abstinence syndrome in Afzalipoor Hospital of Kerman were studied. The treatment started with morphine initially and every four hours the infants were checked. The infants who were diagnosed with uncontrolled symptoms After obtaining informed consent from the parents were randomly divided into two groups and treated with secondary drugs, either phenobarbital or levetiracetam. RESULTS Based on the obtained results, it was clear that there was no significant difference between the hospitalization time of the two infant groups under therapy (phenobarbital: 18.59 days versus Levetiracetam 18.24 days) (P-value = 0.512). Also, there was no significant difference between both groups in terms of the frequency of re-hospitalization during the first week after discharge, the occurrence of complications, and third treatment line prescription (P-value = 0.644). CONCLUSIONS Based on the obtained results, like hospitalization duration time (P-value = 0.512) it seems that levetiracetam can be used to substitute phenobarbital in treating neonatal abstinence syndrome. TRIAL REGISTRATION The current study has been registered in the Iran registry of clinical trials website (fa.irct.ir) on the date 25/2/2022 with registration no. IRCT20211218053444N2.
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Affiliation(s)
- Zahra Jamali
- Department of Pediatrics, School of Medicine, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Hosein Molaei-Farsangi
- Department of Pediatrics, School of Medicine; Clinical Research Development Unit, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran.
| | - Habibeh Ahmadipour
- Department of Social Medicine, School of Medicine, Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Bahareh Bahmanbijari
- Department of Pediatrics, School of Medicine, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Fatemeh Sabzevari
- Department of Pediatrics, School of Medicine, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Zahra Daei Parizi
- Department of Pediatrics, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
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Nikoo M, Kianpoor K, Nikoo N, Javidanbardan S, Kazemi A, Choi F, Vogel M, Gholami A, Tavakoli S, Wong JSH, Moazen-Zadeh E, Givaki R, Jazani M, Mohammadian F, Moghaddam NM, Schütz C, Jang K, Akhondzadeh S, Krausz M. Opium tincture versus methadone for opioid agonist treatment: a randomized controlled trial. Addiction 2023; 118:284-294. [PMID: 35971297 DOI: 10.1111/add.16030] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/03/2022] [Indexed: 01/05/2023]
Abstract
AIM To test if opium tincture (OT) was non-inferior to methadone in retaining participants in opioid agonist treatment (OAT). DESIGN A Phase III, multi-centre, parallel-group, non-inferiority, double-blind randomized controlled trial with an allocation ratio of 1:1. Participants were provided treatment and followed for a period of 85 days. SETTING Four OAT clinics in Iran. PARTICIPANTS Two hundred and four participants with opioid use disorder [mean age (standard deviation) = 37.4 (9.3); female 11.3%] recruited between July 2017 and January 2018. INTERVENTIONS Participants were assigned to either OT (102) or methadone (102) using a patient-centred flexible dosing strategy. MEASUREMENTS Treatment retention over 85 days was the primary outcome. Self-reported opioid use outside treatment and occurrence of adverse events (AEs) were the secondary outcomes. FINDINGS Remaining in treatment at the end of the follow-up were 68.6% in the methadone arm and 59.8% in the OT arm. The relative retention rate of methadone to OT was 1.15 (0.97, 1.36) in both intent-to-treat and per-protocol analyses; non-inferiority was not supported statistically, as the upper bound of the confidence interval exceeded our pre-specified non-inferiority margin (1.25). Opioid use outside treatment was reported by 30.3% of OT (n = 152) and 49.4% of methadone (n = 168) patients, a difference in proportions of -19%: 90% confidence interval (-28%, -10%). The total count of AEs in the OT arm (22 among nine individuals) was significantly higher (P = 0.04) than that in the methadone arm (three among two individuals). Nausea was the most common side effect. CONCLUSION While this study could not conclude the non-inferiority of opium tincture (OT) to methadone for retaining patients in opioid agonist treatment, OT retained 60% of participants to end of follow-up (85 days) and was superior to methadone in reducing self-reported opioid use outside treatment.
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Affiliation(s)
- Mohammadali Nikoo
- Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kiana Kianpoor
- Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nooshin Nikoo
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Alireza Kazemi
- Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Fiona Choi
- Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Marc Vogel
- Division of Substance Use Disorders, Psychiatric Services of Thurgovia, Münsterlingen, Switzerland.,Division of Substance Use Disorders, University of Basel Psychiatric Clinics, Basel, Switzerland
| | - Ali Gholami
- Kian Methadone Maintenance Treatment Clinic, Private Practice, Sari, Mazandaran, Iran
| | - Saeed Tavakoli
- Rooz-e-No, Methadone Maintenance Treatment Clinic (Private Practice), Shiraz, Fars, Iran
| | - James S H Wong
- Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Complex Pain and Addiction Consult Service, Vancouver General Hospital, Vancouver, BC, Canada
| | - Ehsan Moazen-Zadeh
- Addiction Institute of Mount Sinai, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Reza Givaki
- Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Jazani
- Sales, Marketing, Export and Medical Department, Darou Pakhsh Pharmaceutical Manufacturing Company, Tehran, Iran
| | - Fatemeh Mohammadian
- Sales, Marketing, Export and Medical Department, Darou Pakhsh Pharmaceutical Manufacturing Company, Tehran, Iran
| | - Nader Markazi Moghaddam
- Department of Health Management and Economics, School of Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Christian Schütz
- Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kerry Jang
- Institute of Mental Health, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Department of Psychiatry, Faculty of Medicine, Tehran University of Medical Sciences, Iran
| | - Michael Krausz
- Institute of Mental Health, Centre for Health Evaluation and Outcome Sciences, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Cheng F, McMillan C, Morrison A, Berkwitt A, Grossman M. Neonatal Abstinence Syndrome: Management Advances and Therapeutic Approaches. CURRENT ADDICTION REPORTS 2021. [DOI: 10.1007/s40429-021-00387-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) due to opioid withdrawal may result in disruption of the mother-infant relationship, sleep-wake abnormalities, feeding difficulties, weight loss, seizures and neurodevelopmental problems. OBJECTIVES To assess the effectiveness and safety of using an opioid for treatment of NAS due to withdrawal from opioids in newborn infants. SEARCH METHODS We ran an updated search on 17 September 2020 in CENTRAL via Cochrane Register of Studies Web and MEDLINE via Ovid. We also searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for eligible trials. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi- and cluster-RCTs which enrolled infants born to mothers with opioid dependence and who were experiencing NAS requiring treatment with an opioid. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trial eligibility and risk of bias, and independently extracted data. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included 16 trials (1110 infants) with NAS secondary to maternal opioid use in pregnancy. Seven studies at low risk of bias were included in sensitivity analysis. Opioid versus no treatment / usual care: a single trial (80 infants) of morphine and supportive care versus supportive care alone reported no difference in treatment failure (risk ratio (RR) 1.29, 95% confidence interval (CI) 0.41 to 4.07; very low certainty evidence). No infant had a seizure. The trial did not report mortality, neurodevelopmental disability and adverse events. Morphine increased days hospitalisation (mean difference (MD) 15.00, 95% CI 8.86 to 21.14; very low certainty evidence) and treatment (MD 12.50, 95% CI 7.52 to 17.48; very low certainty evidence), but decreased days to regain birthweight (MD -2.80, 95% CI -5.33 to -0.27) and duration (minutes) of supportive care each day (MD -197.20, 95% CI -274.15 to -120.25). Morphine versus methadone: there was no difference in treatment failure (RR 1.59, 95% CI 0.95 to 2.67; 2 studies, 147 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study reported no difference in days hospitalisation (MD 1.40, 95% CI -3.08 to 5.88; 116 infants; low certainty evidence), whereas data from two studies found an increase in days treatment (MD 2.71, 95% CI 0.22 to 5.21; 147 infants; low certainty) for infants treated with morphine. A single study reported no difference in breastfeeding, adverse events, or out of home placement. Morphine versus sublingual buprenorphine: there was no difference in treatment failure (RR 0.79, 95% CI 0.36 to 1.74; 3 studies, 113 infants; very low certainty evidence). Neonatal or infant mortality and neurodevelopmental disability were not reported. There was moderate certainty evidence of an increase in days hospitalisation (MD 11.45, 95% CI 5.89 to 17.01; 3 studies, 113 infants), and days treatment (MD 12.79, 95% CI 7.57 to 18.00; 3 studies, 112 infants) for infants treated with morphine. A single adverse event (seizure) was reported in infants exposed to buprenorphine. Morphine versus diluted tincture of opium (DTO): a single study (33 infants) reported no difference in days hospitalisation, days treatment or weight gain (low certainty evidence). Opioid versus clonidine: a single study (31 infants) reported no infant with treatment failure in either group. This study did not report seizures, neonatal or infant mortality and neurodevelopmental disability. There was low certainty evidence for no difference in days hospitalisation or days treatment. This study did not report adverse events. Opioid versus diazepam: there was a reduction in treatment failure from use of an opioid (RR 0.43, 95% CI 0.23 to 0.80; 2 studies, 86 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study of 34 infants comparing methadone versus diazepam reported no difference in days hospitalisation or days treatment (very low certainty evidence). Adverse events were not reported. Opioid versus phenobarbital: there was a reduction in treatment failure from use of an opioid (RR 0.51, 95% CI 0.35 to 0.74; 6 studies, 458 infants; moderate certainty evidence). Subgroup analysis found a reduction in treatment failure in trials titrating morphine to ≧ 0.5 mg/kg/day (RR 0.21, 95% CI 0.10 to 0.45; 3 studies, 230 infants), whereas a single study using morphine < 0.5 mg/kg/day reported no difference compared to use of phenobarbital (subgroup difference P = 0.05). Neonatal or infant mortality and neurodevelopmental disability were not reported. A single study (111 infants) of paregoric versus phenobarbital reported seven infants with seizures in the phenobarbital group, whereas no seizures were reported in two studies (170 infants) comparing morphine to phenobarbital. There was no difference in days hospitalisation or days treatment. A single study (96 infants) reported no adverse events in either group. Opioid versus chlorpromazine: there was a reduction in treatment failure from use of morphine versus chlorpromazine (RR 0.08, 95% CI 0.01 to 0.62; 1 study, 90 infants; moderate certainty evidence). No seizures were reported in either group. There was low certainty evidence for no difference in days treatment. This trial reported no adverse events in either group. None of the included studies reported time to control of NAS. Data for duration and severity of NAS were limited, and we were unable to use these data in quantitative synthesis. AUTHORS' CONCLUSIONS Compared to supportive care alone, the addition of an opioid may increase duration of hospitalisation and treatment, but may reduce days to regain birthweight and the duration of supportive care each day. Use of an opioid may reduce treatment failure compared to phenobarbital, diazepam or chlorpromazine. Use of an opioid may have little or no effect on duration of hospitalisation or treatment compared to use of phenobarbital, diazepam or chlorpromazine. The type of opioid used may have little or no effect on the treatment failure rate. Use of buprenorphine probably reduces duration of hospitalisation and treatment compared to morphine, but there are no data for time to control NAS with buprenorphine, and insufficient evidence to determine safety. There is insufficient evidence to determine the effectiveness and safety of clonidine.
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Affiliation(s)
- Angelika Zankl
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
| | - Jill Martin
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Jane G Davey
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - David A Osborn
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
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Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) due to opioid withdrawal may result in disruption of the mother-infant relationship, sleep-wake abnormalities, feeding difficulties, weight loss, seizures and neurodevelopmental problems. OBJECTIVES To assess the effectiveness and safety of using a sedative versus control (placebo, usual treatment or non-pharmacological treatment) for NAS due to withdrawal from opioids and determine which type of sedative is most effective and safe for NAS due to withdrawal from opioids. SEARCH METHODS We ran an updated search on 17 September 2020 in CENTRAL via CRS Web and MEDLINE via Ovid. We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We included trials enrolling infants with NAS born to mothers with an opioid dependence with more than 80% follow-up and using randomised, quasi-randomised and cluster-randomised allocation to sedative or control. DATA COLLECTION AND ANALYSIS Three review authors assessed trial eligibility and risk of bias, and independently extracted data. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 10 trials (581 infants) with NAS secondary to maternal opioid use in pregnancy. There were multiple comparisons of different sedatives and regimens. There were limited data available for use in sensitivity analysis of studies at low risk of bias. Phenobarbital versus supportive care: one study reported there may be little or no difference in treatment failure with phenobarbital and supportive care versus supportive care alone (risk ratio (RR) 2.73, 95% confidence interval (CI) 0.94 to 7.94; 62 participants; very low-certainty evidence). No infant had a clinical seizure. The study did not report mortality, neurodevelopmental disability and adverse events. There may be an increase in days' hospitalisation and treatment from use of phenobarbital (hospitalisation: mean difference (MD) 20.80, 95% CI 13.64 to 27.96; treatment: MD 17.90, 95% CI 11.98 to 23.82; both 62 participants; very low-certainty evidence). Phenobarbital versus diazepam: there may be a reduction in treatment failure with phenobarbital versus diazepam (RR 0.39, 95% CI 0.24 to 0.62; 139 participants; 2 studies; low-certainty evidence). The studies did not report mortality, neurodevelopmental disability and adverse events. One study reported there may be little or no difference in days' hospitalisation and treatment (hospitalisation: MD 3.89, 95% CI -1.20 to 8.98; 32 participants; treatment: MD 4.30, 95% CI -0.73 to 9.33; 31 participants; both low-certainty evidence). Phenobarbital versus chlorpromazine: there may be a reduction in treatment failure with phenobarbital versus chlorpromazine (RR 0.55, 95% CI 0.33 to 0.92; 138 participants; 2 studies; very low-certainty evidence), and no infant had a seizure. The studies did not report mortality and neurodevelopmental disability. One study reported there may be little or no difference in days' hospitalisation (MD 7.00, 95% CI -3.51 to 17.51; 87 participants; low-certainty evidence) and 0/100 infants had an adverse event. Phenobarbital and opioid versus opioid alone: one study reported no infants with treatment failure and no clinical seizures in either group (low-certainty evidence). The study did not report mortality, neurodevelopmental disability and adverse events. One study reported there may be a reduction in days' hospitalisation for infants treated with phenobarbital and opioid (MD -43.50, 95% CI -59.18 to -27.82; 20 participants; low-certainty evidence). Clonidine and opioid versus opioid alone: one study reported there may be little or no difference in treatment failure with clonidine and dilute tincture of opium (DTO) versus DTO alone (RR 0.09, 95% CI 0.01 to 1.59; 80 participants; very low-certainty evidence). All five infants with treatment failure were in the DTO group. There may be little or no difference in seizures (RR 0.14, 95% CI 0.01 to 2.68; 80 participants; very low-certainty evidence). All three infants with seizures were in the DTO group. There may be little or no difference in mortality after discharge (RR 7.00, 95% CI 0.37 to 131.28; 80 participants; very low-certainty evidence). All three deaths were in the clonidine and DTO group. The study did not report neurodevelopmental disability. There may be little or no difference in days' treatment (MD -4.00, 95% CI -8.33 to 0.33; 80 participants; very low-certainty evidence). One adverse event occurred in the clonidine and DTO group. There may be little or no difference in rebound NAS after stopping treatment, although all seven cases were in the clonidine and DTO group. Clonidine and opioid versus phenobarbital and opioid: there may be little or no difference in treatment failure (RR 2.27, 95% CI 0.98 to 5.25; 2 studies, 93 participants; very low-certainty evidence). One study reported one infant in the clonidine and morphine group had a seizure, and there were no infant mortalities. The studies did not report neurodevelopmental disability. There may be an increase in days' hospitalisation and days' treatment with clonidine and opioid versus phenobarbital and opioid(hospitalisation: MD 7.13, 95% CI 6.38 to 7.88; treatment: MD 7.57, 95% CI 3.97 to 11.17; both 2 studies, 91 participants; low-certainty evidence). There may be little or no difference in adverse events (RR 1.55, 95% CI 0.44 to 5.40; 2 studies, 93 participants; very low-certainty evidence). However, there was oversedation only in the phenobarbital and morphine group; and hypotension, rebound hypertension and rebound NAS only in the clonidine and morphine group. AUTHORS' CONCLUSIONS There is very low-certainty evidence that phenobarbital increases duration of hospitalisation and treatment, but reduces days to regain birthweight and duration of supportive care each day compared to supportive care alone. There is low-certainty evidence that phenobarbital reduces treatment failure compared to diazepam and very low-certainty evidence that phenobarbital reduces treatment failure compared to chlorpromazine. There is low-certainty evidence of an increase in days' hospitalisation and days' treatment with clonidine and opioid compared to phenobarbital and opioid. There are insufficient data to determine the safety and incidence of adverse events for infants treated with combinations of opioids and sedatives including phenobarbital and clonidine.
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Affiliation(s)
- Angelika Zankl
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
| | - Jill Martin
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Jane G Davey
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - David A Osborn
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
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Flannery T, Davis JM, Czynski AJ, Dansereau LM, Oliveira EL, Camardo SA, Lester BM. Neonatal Abstinence Syndrome Severity Index Predicts 18-Month Neurodevelopmental Outcome in Neonates Randomized to Morphine or Methadone. J Pediatr 2020; 227:101-107.e1. [PMID: 32805259 PMCID: PMC7731918 DOI: 10.1016/j.jpeds.2020.08.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/09/2020] [Accepted: 08/12/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To develop an index to determine which opioid-exposed neonates have the most severe neonatal abstinence syndrome (NAS). STUDY DESIGN Full-term neonates with NAS (n = 116) from mothers maintained on methadone or buprenorphine were enrolled from 8 sites into a randomized clinical trial of morphine vs methadone. Ninety-nine (85%) were evaluated at hospital discharge using the NICU Network Neurobehavioral Scale (NNNS). At 18 months, 83 of 99 (83.8%) were evaluated with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III), and 77 of 99 (77.7%) were evaluated with the Child Behavior Checklist (CBCL). RESULTS Cluster analysis was used to define high (n = 21) and low (n = 77) NAS severity. Compared with infants in the low NAS severity cluster, infants in the high NAS severity cluster had a longer length of stay (P < .001), longer length of stay due to NAS (P < .001), longer duration of treatment due to NAS (P < .001), and higher total dose of the study drug (P < .001) and were more likely to have received phenobarbital (P < .001), to have been treated with morphine (P = .020), and to have an atypical NNNS profile (P = .005). The 2 groups did not differ in terms of maximum Finnegan score. At 18 months, in unadjusted analyses, compared with the high-severity cluster, the low-severity cluster had higher scores on the Bayley-III Cognitive (P = .013), Language (P < .001), and Motor (P = .041) composites and less total behavior problems on the CBCL (P = .028). In adjusted analyses, the difference in the Bayley-III Language composite remained (P = .013). CONCLUSIONS Presumptive measures of NAS severity can be aggregated to develop an index that predicts developmental outcomes at age 18 months.
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Affiliation(s)
- Tess Flannery
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Jonathan M Davis
- Department of Pediatrics, The Floating Hospital for Children at Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Science Institute, Boston, MA; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Adam J Czynski
- Department of Pediatrics, Warren Alpert Medical School of Brown University and Women and Infants Hospital, Providence, RI
| | - Lynne M Dansereau
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Erica L Oliveira
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Samantha A Camardo
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Barry M Lester
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI; Department of Pediatrics, Warren Alpert Medical School of Brown University and Women and Infants Hospital, Providence, RI; Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI.
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Grossman MR, Berkwitt AK, Osborn RR, Citarella BV, Hochreiter D, Bizzarro MJ. Evaluating the effect of hospital setting on outcomes for neonatal abstinence syndrome. J Perinatol 2020; 40:1483-1488. [PMID: 32086436 DOI: 10.1038/s41372-020-0621-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/28/2020] [Accepted: 02/06/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES This study aims to evaluate the impact of hospital setting on outcomes for infants with neonatal abstinence syndrome. STUDY DESIGN We conducted a retrospective study in two hospitals and three different hospital units. The inpatient group (n = 60) was managed on general inpatient floors, the NICU group (n = 50) was managed primarily in an NICU, and the combination group (n = 49) was managed in both NICU and inpatient units. The primary outcome was length of stay. Secondary outcomes included breastfeeding rates, morphine usage rates, and hospital costs. RESULTS The length of stay in the inpatient group (8.5 days) was significantly lower than the combination group (18 days) and NICU group (23 days) (p < 0.01). The inpatient group had significantly lower rates of morphine treatment and hospital costs with no difference in breastfeeding rates. CONCLUSIONS Infants with neonatal abstinence syndrome had a significantly shorter length of stay and less use of morphine when managed on inpatient units versus NICU.
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Affiliation(s)
- Matthew R Grossman
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.
| | - Adam K Berkwitt
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Rachel R Osborn
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Brett V Citarella
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Daniela Hochreiter
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
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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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MacMillan KDL. Neonatal Abstinence Syndrome: Review of Epidemiology, Care Models, and Current Understanding of Outcomes. Clin Perinatol 2019; 46:817-832. [PMID: 31653310 DOI: 10.1016/j.clp.2019.08.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Kathryn Dee Lizcano MacMillan
- Division of Neonatology and Newborn Medicine, Massachusetts General Hospital for Children, Good Samaritan Medical Center, 55 Fruit Street, Founders 5-530, Boston, MA 02114, USA; Division of Pediatric Hospital Medicine, Massachusetts General Hospital for Children, Good Samaritan Medical Center, 55 Fruit Street, Founders 5-530, Boston, MA 02114, USA.
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Comparative effectiveness of opioid replacement agents for neonatal opioid withdrawal syndrome: a systematic review and meta-analysis. J Perinatol 2019; 39:1535-1545. [PMID: 31316147 PMCID: PMC7784556 DOI: 10.1038/s41372-019-0437-3] [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: 04/07/2019] [Accepted: 05/22/2019] [Indexed: 12/29/2022]
Abstract
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.
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11
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Ghazanfarpour M, Najafi MN, Roozbeh N, Mashhadi ME, Keramat-Roudi A, Mégarbane B, Tsatsakis A, Moghaddam MMM, Rezaee R. Therapeutic approaches for neonatal abstinence syndrome: a systematic review of randomized clinical trials. ACTA ACUST UNITED AC 2019; 27:423-431. [PMID: 31093953 DOI: 10.1007/s40199-019-00266-3] [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] [Received: 01/11/2019] [Accepted: 04/11/2019] [Indexed: 11/25/2022]
Abstract
Neonatal abstinence syndrome (NAS) which is observed in 55-94% of the newborns from opioids-taking mothers produces deleterious neurological symptoms. Various pharmacological therapies have been investigated in neonates with NAS. This article reviews all studies on NAS treatment to analyze the duration of treatment, length of hospitalization and possible drug adverse effects. The search was limited to the randomized clinical trials which examined the treatments of neonates with NAS. Scientific databases including PubMed, Cochrane Library, ISI Web of Science, Embase and Scopus were systematically searched. Retrieved articles were reviewed by two researchers and evaluated using the JADAD scoring system. Finally, the treatment duration, hospitalization length and drug side-effects were extracted. Methadone, buprenorphine and clonidine were found more effective than morphine. Diluted tincture of opium (DTO) in combination with phenobarbital or clonidine was significantly more effective than DTO alone. Clonidine was a significantly better adjunctive therapy than phenobarbital in reducing morphine treatment days. No significant difference was observed between morphine and DTO effectiveness. Deciding the optimal regimen to manage symptomatic NAS, as a single or an adjunct therapy is not possible based on the literature, due to the low quality, small size and short-term treatment considered in the published studies. Graphical abstract Process of selecting trials included in the present systematic review.
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Affiliation(s)
- Masumeh Ghazanfarpour
- Department of Nursing and Midwifery, Razi School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
| | - Mona Najaf Najafi
- Clinical Research Unit, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nasibeh Roozbeh
- Mother and Child Welfare Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | | | - Atefeh Keramat-Roudi
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Paris-Diderot University, INSERM UMRS-1144, Paris, France
| | - Aristidis Tsatsakis
- Center of Toxicology Science & Research, Medical School, University of Crete, Heraklion, Crete, Greece
| | | | - Ramin Rezaee
- Clinical Research Unit, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
- Aristotle University of Thessaloniki, Department of Chemical Engineering, Environmental Engineering Laboratory, University Campus, Thessaloniki, 54124, Greece.
- HERACLES Research Center on the Exposome and Health, Center for Interdisciplinary Research and Innovation, Bldg. B, 10th km Thessaloniki-Thermi Road, Thessaloniki, 57001, Greece.
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Abstract
Neonates exposed prenatally to opioids will often develop a collection of withdrawal signs known as neonatal abstinence syndrome (NAS). The incidence of NAS has substantially increased in recent years placing an increasing burden on the healthcare system. Traditional approaches to assessment and management have relied on symptom-based scoring tools and utilization of slowly decreasing doses of medication, though newer models of care focused on non-pharmacologic interventions and rooming-in have demonstrated promise in reducing length of hospital stay and medication usage. Data on long-term outcomes for both traditional and newer approaches to care of infants with NAS is limited and an important area of future research. This review will examine the history, incidence and pathophysiology of NAS. We will also review diagnostic screening approaches, scoring tools, differing management approaches and conclude with recommendations for continued work to improve the care of infants with NAS.
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Affiliation(s)
- Matthew Grossman
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States.
| | - Adam Berkwitt
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States
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13
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Mangat AK, Schmölzer GM, Kraft WK. Pharmacological and non-pharmacological treatments for the Neonatal Abstinence Syndrome (NAS). Semin Fetal Neonatal Med 2019; 24:133-141. [PMID: 30745219 PMCID: PMC6451887 DOI: 10.1016/j.siny.2019.01.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Neonatal abstinence syndrome is defined by signs and symptoms of withdrawal that infants develop after intrauterine maternal drug exposure. All infants with documented in utero opioid exposure, or a high pre-test probability of exposure should have monitoring with a standard assessment instrument such as a Finnegan Score. A Finnegan score of >8 is suggestive of opioid exposure, even in the absence of declared use during pregnancy. At least half of infants in most locales can be treated without the use of pharmacologic means. For this reason, symptom scores will drive the decision for pharmacologic therapy. Nevertheless, all infants, regardless of initial manifestations, should be first be managed with non-pharmacologic approaches which in turn, should not be considered as the sole alternative to drug therapy, but rather, as the base upon which all patients are treated. Those who continue to have symptoms despite supportive care should be pharmacologically treated, which in the most severe cases, is life-saving.
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Affiliation(s)
- A K Mangat
- Faculty of Science, University of Alberta, Edmonton, Alberta, Canada; Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - G M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - W K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
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Martins F, Oppolzer D, Santos C, Barroso M, Gallardo E. Opioid Use in Pregnant Women and Neonatal Abstinence Syndrome-A Review of the Literature. TOXICS 2019; 7:E9. [PMID: 30781484 PMCID: PMC6468487 DOI: 10.3390/toxics7010009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/10/2019] [Accepted: 02/13/2019] [Indexed: 02/07/2023]
Abstract
Opiate use during pregnancy has been an increasing problem over the last two decades, making it an important social and health concern. The use of such substances may have serious negative outcomes in the newborn, and clinical and cognitive conditions have been reported, including neonatal abstinence syndrome, developmental problems, and lower cognitive performance. These conditions are common when opiates are used during pregnancy, making the prescription of these kinds of drugs problematic. Moreover, the mother may develop opiate addiction, thus, increasing the likelihood of the infant being born with any of those conditions. This paper reviews the use of opiates during pregnancy and focuses mainly on the neonatal abstinence syndrome. First, the commonly prescribed opiates will be identified, namely those usually involved in cases of addiction and/or neonatal abstinence syndrome. Second, published approaches to deal with those problems will be presented and discussed, including the treatment of both the mother and the infant. Finally, we will outline the treatments that are safest and most efficient, and will define future goals, approaches, and research directions for the scientific community regarding this problem.
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Affiliation(s)
- Fábio Martins
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - David Oppolzer
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - Catarina Santos
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - Mário Barroso
- Serviço de Química e Toxicologia Forenses, Instituto de Medicina Legal e Ciências Forenses-Delegação do Sul, 1150-334 Lisboa, Portugal.
| | - Eugenia Gallardo
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
- Laboratório de Fármaco-Toxicologia-UBIMedical, Universidade da Beira Interior, 6200-284 Covilhã, Portugal.
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Abstract
Neonatal abstinence syndrome refers to the signs and symptoms attributed to the cessation of prenatal exposure (via placental transfer) to various substances. This Primer focuses on neonatal abstinence syndrome caused by opioid use during pregnancy - neonatal opioid withdrawal syndrome (NOWS). As the global prevalence of opioid use has alarmingly increased, so has the incidence of NOWS. NOWS can manifest with varying severity or not at all, for unknown reasons, but is likely to be associated with multiple factors, both maternal (for example, smoking and additional substance exposures) and neonatal (gestational age, sex and genetics). Care for the infant with NOWS begins with addressing the issues experienced by pregnant women with opioid use disorder. Co-occurring mental illness, economic hardship, intimate partner violence, infectious diseases and limited access to care are common in these women and can result in poor maternal and neonatal outcomes. Although there is no consensus regarding optimal NOWS management, non-pharmacological interventions (such as breastfeeding and rooming-in of the mother and the baby) have become a priority, as they can ameliorate symptoms without the need for further opioid exposure. Untreated NOWS can be associated with morbidity in early infancy, and the long-term consequences of fetal opioid exposure are only beginning to be understood.
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Affiliation(s)
- Mara G Coyle
- Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Susan B Brogly
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Mahmoud S Ahmed
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Stephen W Patrick
- Vanderbilt Center for Child Health Policy, Department of Pediatrics and Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, University of North Carolina, Carrboro, NC, USA
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Lacaze-Masmonteil T, O’Flaherty P. La prise en charge des nouveau-nés dont la mère a pris des opioïdes pendant la grossesse. Paediatr Child Health 2018. [DOI: 10.1093/pch/pxx200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Pat O’Flaherty
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
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Lacaze-Masmonteil T, O'Flaherty P. Managing infants born to mothers who have used opioids during pregnancy. Paediatr Child Health 2018; 23:220-226. [PMID: 29769809 DOI: 10.1093/pch/pxx199] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The incidence of infant opioid withdrawal has grown rapidly in many countries, including Canada, in the last decade, presenting significant health and early brain development concerns. Increased prenatal exposure to opioids reflects rising prescription opioid use as well as the presence of both illegal opiates and opioid-substitution therapies. Infants are at high risk for experiencing symptoms of abstinence or withdrawal that may require assessment and treatment. This practice point focuses specifically on the effect(s) of opioid withdrawal and current management strategies in the care of infants born to mothers with opioid dependency.
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Affiliation(s)
| | - Pat O'Flaherty
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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Klaman SL, Isaacs K, Leopold A, Perpich J, Hayashi S, Vender J, Campopiano M, Jones HE. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med 2018; 11:178-190. [PMID: 28406856 PMCID: PMC5457836 DOI: 10.1097/adm.0000000000000308] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 02/12/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The prevalence of opioid use disorder (OUD) during pregnancy is increasing. Practical recommendations will help providers treat pregnant women with OUD and reduce potentially negative health consequences for mother, fetus, and child. This article summarizes the literature review conducted using the RAND/University of California, Los Angeles Appropriateness Method project completed by the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration to obtain current evidence on treatment approaches for pregnant and parenting women with OUD and their infants and children. METHODS Three separate search methods were employed to identify peer-reviewed journal articles providing evidence on treatment methods for women with OUD who are pregnant or parenting, and for their children. Identified articles were reviewed for inclusion per study guidelines and relevant information was abstracted and summarized. RESULTS Of the 1697 articles identified, 75 were included in the literature review. The perinatal use of medication for addiction treatment (MAT, also known as medication-assisted treatment), either methadone or buprenorphine, within comprehensive treatment is the most accepted clinical practice, as withdrawal or detoxification risks relapse and treatment dropout. Medication increases may be needed with advancing pregnancy, and are not associated with more severe neonatal abstinence syndrome (NAS). Switching medication prenatally is usually not recommended as it can destabilize opioid abstinence. Postnatally, breastfeeding is seen as beneficial for the infant for women who are maintained on a stable dose of opioid agonist medication. Less is known about ideal pain management and postpartum dosing regimens. NAS appears generally less severe following prenatal exposure to buprenorphine versus methadone. Frontline NAS medication treatments include protocol-driven methadone and morphine dosing in the context of nonpharmacological supports. CONCLUSIONS Women with OUD can be treated with methadone or buprenorphine during pregnancy. NAS is an expected and manageable condition. Although research has substantially advanced, opportunities to guide future research to improve maternal and infant outcomes are provided.
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Affiliation(s)
- Stacey L Klaman
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC (SLK); JBS International, Inc., North Bethesda, MD (KI, AL, JP, SH, JV); Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, Rockville, MD (MC); UNC Horizons, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (HEJ); Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD (HEJ)
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Treating Neonatal Abstinence Syndrome from Clinical Perspectives. IRANIAN JOURNAL OF PEDIATRICS 2017. [DOI: 10.5812/ijp.6266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pharmacotherapy for Neonatal Abstinence Syndrome: Choosing the Right Opioid or No Opioid at All. Neonatal Netw 2017; 35:314-20. [PMID: 27636696 DOI: 10.1891/0730-0832.35.5.314] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Neonatal abstinence syndrome (NAS) from in utero opioid exposure has reached epidemic levels in the United States. Although nonpharmacologic therapies form the foundation of care, many neonates require pharmacotherapy. Morphine represents the most widely used first-line agent and effectively treats the symptoms of withdrawal. However, methadone or buprenorphine may facilitate earlier discharge. Although phenobarbital is traditionally used when opioids fail, clonidine may be a more appropriate adjunctive agent to minimize negative neurodevelopmental impact. Consideration of the available data allows hospitals to generate effective pharmacologic strategies to manage NAS while further research continues.
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Pryor JR, Maalouf FI, Krans EE, Schumacher RE, Cooper WO, Patrick SW. The opioid epidemic and neonatal abstinence syndrome in the USA: a review of the continuum of care. Arch Dis Child Fetal Neonatal Ed 2017; 102:F183-F187. [PMID: 28073819 PMCID: PMC5730450 DOI: 10.1136/archdischild-2015-310045] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 12/05/2016] [Accepted: 12/07/2016] [Indexed: 11/03/2022]
Abstract
As the prescription opioid epidemic grew in the USA, its impact extended to pregnant women and their infants. This review summarises how increasing rates of neonatal abstinence syndrome resulted in a need to improve care to pregnant women and opioid-exposed infants. We discuss the variations in care delivery with particular emphasis on screening at-risk mothers, scoring systems for neonatal drug withdrawal, type and duration of pharmacotherapy, and discharge safety.
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Affiliation(s)
- Jason R Pryor
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA,Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee, USA
| | - Faouzi I Maalouf
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA,Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Women’s Research Institute University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert E Schumacher
- Department of Pediatrics, University of Michigan Health Systems, Ann Arbor, Michigan, USA
| | - William O Cooper
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA,Vanderbilt Center for Health Services Research, Nashville, Tennessee, USA,Department of Health Policy, Vanderbilt University, Nashville, Tennessee, USA
| | - Stephen W Patrick
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA,Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee, USA,Vanderbilt Center for Health Services Research, Nashville, Tennessee, USA,Department of Health Policy, Vanderbilt University, Nashville, Tennessee, USA
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Nikoo M, Nikoo N, Anbardan SJ, Amiri A, Vogel M, Choi F, Sepehry AA, Bagheri Valoojerdi AH, Jang K, Schütz C, Akhondzadeh S, Krausz M. Tincture of opium for treating opioid dependence: a systematic review of safety and efficacy. Addiction 2017; 112:415-429. [PMID: 27740713 DOI: 10.1111/add.13628] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 07/15/2016] [Accepted: 10/05/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Recently, there has been a growing interest in using opium tincture (OT) for treating opioid dependence in certain regions. We aimed to assess the evidence on its safety and efficacy for this indication. METHODS We searched several databases (CENTRAL, Medline, EMBASE, Web of Science, PsychINFO, ProQuest Dissertation and Theses Database, Iran Medex, clinicaltrials.gov and who.int/trialsearch) with no language or publication date limitations. Two reviewers selected randomized controlled trials (RCT), cohort/case-control/cross-sectional studies and case-series on safety or efficacy of OT for treating opioid dependence and then extracted reported measures of mentioned outcomes from selected studies. We used the Effective Public Health Practice Project (EPHPP) Quality Assessment tool for appraisal. RESULTS From nine selected studies; in three RCTs and one cohort analytical analysis on detoxification, 110 patients were treated with 15-140 morphine equivalents/day (mEq/d) of OT; in four prospective and one retrospective uncontrolled case-series on long-term/maintenance treatment, 570 patients were treated with 100-400 mEq/d of OT. Only two studies on detoxification included a comparison: one concluded equal efficacy of OT and methadone in suppressing withdrawal symptoms (P = 0.32) and the other concluded OT to be less efficacious than buprenorphine/naloxone in suppressing withdrawal [OT = 12.20, 95% confidence interval (CI) = 11.00, 13.40]; control: 5.20 (95% CI = 4.69, 5.71) and craving (OT = 303.0, 95% CI = -144.664, 750.664; control: 0.0) but not significantly different (P = 0.26) in retaining participants in treatment. No major adverse events were reported. CONCLUSIONS Conclusive recommendations about the safety and efficacy of opium tincture for treating opioid dependence are not possible at this time.
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Affiliation(s)
- Mohammadali Nikoo
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Institute of Mental Health, Centre of Health Evaluation and Outcome Sciences (CHEOS), University of British Columbia, Vancouver, BC, Canada
| | - Nooshin Nikoo
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sanam Javid Anbardan
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Psychiatry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Afshar Amiri
- Roozbeh substance use treatment clinic, Tehran, Iran
| | - Marc Vogel
- Psychiatric University Hospital, Basel, Switzerland
| | - Fiona Choi
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Institute of Mental Health, Centre of Health Evaluation and Outcome Sciences (CHEOS), University of British Columbia, Vancouver, BC, Canada
| | - Amir Ali Sepehry
- Department of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Kerry Jang
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Institute of Mental Health, Centre of Health Evaluation and Outcome Sciences (CHEOS), University of British Columbia, Vancouver, BC, Canada
| | - Christian Schütz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Institute of Mental Health, Centre of Health Evaluation and Outcome Sciences (CHEOS), University of British Columbia, Vancouver, BC, Canada
| | - Shahin Akhondzadeh
- Department of Psychiatry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Institute of Mental Health, Centre of Health Evaluation and Outcome Sciences (CHEOS), University of British Columbia, Vancouver, BC, Canada
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Devlin LA, Lau T, Radmacher PG. Decreasing Total Medication Exposure and Length of Stay While Completing Withdrawal for Neonatal Abstinence Syndrome during the Neonatal Hospital Stay. Front Pediatr 2017; 5:216. [PMID: 29067285 PMCID: PMC5641300 DOI: 10.3389/fped.2017.00216] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/25/2017] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Neonatal abstinence syndrome (NAS) is a rapidly growing public health concern that has considerably increased health-care utilization and health-care costs. In an effort to curtail costs, attempts have been made to complete withdrawal as an outpatient. Outpatient therapy has been shown to prolong exposure to medications, which may negatively impact neurodevelopmental and behavioral outcomes. We hypothesized that the implementation of a modified NAS protocol would decrease total drug exposure and length of stay while allowing for complete acute drug withdrawal during the neonatal hospital stay. METHODS Data were derived retrospectively from medical records of term (≥37 0/7) infants with NAS who were treated with pharmacologic therapy in the University of Louisville Hospital Neonatal Intensive Care Unit from 2005 to 2015. The pharmacologic protocol (SP1) for infants treated between 2005 and March 2014 (n = 146) dosed oral morphine every 4 h and utilized phenobarbital as adjuvant therapy. Protocol 2 (SP2) initiated after March 2014 (n = 44) dosed morphine every 3 h and used clonidine as adjuvant therapy. Charts were reviewed for demographic information and maternal drug history. Maternal and infant toxicology screens were recorded. The length of morphine therapy and need for adjuvant drug therapy were noted. Length of stay was derived from admission and discharge dates. RESULTS The length of morphine therapy was decreased by 8.5 days from 35 to 26.5 days (95% CI 4.5-12 days) for infants treated with SP2 vs. SP1 (p < 0.001). The need for adjuvant pharmacologic therapy was decreased by 24% in patients treated with SP2 vs. SP1 (p = 0.004). The length of stay was decreased by 9 days from 42 to 33 days (95% CI 5.1-13 days) for infants treated with SP2 vs. SP1 (p < 0.001). The decreased length of stay resulted in an average reduction of hospital charges by $27,090 per patient in adjusted 2015 US Dollars. CONCLUSION This study demonstrates that total drug exposure and length of stay can be reduced while successfully completing acute withdrawal during the neonatal hospital stay.
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Affiliation(s)
- Lori A Devlin
- Division of Neonatal Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, United States
| | - Timothy Lau
- Department of Educational and Counseling Psychology, University of Louisville, Louisville, KY, United States
| | - Paula G Radmacher
- Division of Neonatal Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, United States
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Neonatal Adaptation Issues After Maternal Exposure to Prescription Drugs: Withdrawal Syndromes and Residual Pharmacological Effects. Drug Saf 2016; 39:903-24. [DOI: 10.1007/s40264-016-0435-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
Opioid use in pregnancy has increased dramatically over the past decade. Since prenatal opioid use is associated with numerous obstetrical and neonatal complications, this now has become a major public health problem. In particular, in utero opioid exposure can result in neonatal abstinence syndrome (NAS) which is a serious condition characterized by central nervous system hyperirritability and autonomic nervous system dysfunction. The present review seeks to define current practices regarding the approach to the pregnant mother and neonate with prenatal opiate exposure. Although the cornerstone of prenatal management of opioid dependence is opioid maintenance therapy, the ideal agent has yet to be definitively established. Pharmacologic management of NAS is also highly variable and may include an opioid, barbiturate, and/or α-agonist. Genetic factors appear to be associated with the incidence and severity of NAS. Establishing pharmacogenetic risk factors for the development of NAS has the potential for creating opportunities for "personalized genomic medicine" and novel, individualized therapeutic interventions.
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Terasaki LS, Gomez J, Schwarz JM. An examination of sex differences in the effects of early-life opiate and alcohol exposure. Philos Trans R Soc Lond B Biol Sci 2016; 371:20150123. [PMID: 26833841 DOI: 10.1098/rstb.2015.0123] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2015] [Indexed: 11/12/2022] Open
Abstract
Early-life exposure to drugs and alcohol is one of the most preventable causes of developmental, behavioural and learning disorders in children. Thus a significant amount of basic, animal and human research has focused on understanding the behavioural consequences and the associated neural effects of exposure to drugs and alcohol during early brain development. Despite this, much of the previous research that has been done on this topic has used predominantly male subjects or rodents. While many of the findings from these male-specific studies may ultimately apply to females, the purpose of this review is to highlight the research that has also examined sex as a factor and found striking differences between the sexes in their response to early-life opiate and alcohol exposure. Finally, we will also provide a framework for scientists interested in examining sex as a factor in future experiments that specifically examine the consequences of early-life drug and alcohol exposure.
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Affiliation(s)
- Laurne S Terasaki
- Department of Psychological and Brain Sciences, University of Delaware, 108 Wolf Hall, Newark, DE 19716, USA
| | - Julie Gomez
- Department of Psychological and Brain Sciences, University of Delaware, 108 Wolf Hall, Newark, DE 19716, USA
| | - Jaclyn M Schwarz
- Department of Psychological and Brain Sciences, University of Delaware, 108 Wolf Hall, Newark, DE 19716, USA
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Jones HE, Fielder A. Neonatal abstinence syndrome: Historical perspective, current focus, future directions. Prev Med 2015; 80:12-7. [PMID: 26232620 DOI: 10.1016/j.ypmed.2015.07.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 07/21/2015] [Accepted: 07/21/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) occurs following prenatal opioid exposure. It is characterized by signs and symptoms indicating central nervous system hyperirritability and autonomic nervous system, gastrointestinal tract, and respiratory system dysfunction. OBJECTIVE This article: (1) briefly reviews NAS history, including initial identification, assessment, and treatment efforts; (2) summarizes the current status of and current issues surrounding recent NAS assessment and treatment, and (3) details future directions in NAS conceptualization, measurement, and treatment. RESULTS Mortality rate estimates in neonates treated for NAS exceeded 33%, and surpassed 90% for un-treated infants during the late-1800s until the mid-1900s. The focus of both assessment and treatment over the past 50years is predominantly due to two forces. First, methadone pharmacotherapy for "heroin addiction" led to women in methadone maintenance programs who were, or became pregnant. The second was defining NAS and developing a measure of neonatal withdrawal, the Neonatal Abstinence Scoring System (NASS). Various NAS treatment protocols were based on the NASS as well as other NAS measures. CONCLUSIONS Future research must focus on psychometrically sound screening and assessment measures of neonatal opioid withdrawal for premature, term and older infants, measuring and treating possible withdrawal from non-opioids, particularly benzodiazepines, integrated non-pharmacological treatment of NAS, weight-based versus symptom-based treatment of NAS, and second-line treatment for NAS.
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Affiliation(s)
- Hendrée E Jones
- UNC Horizons and Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA; Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA.
| | - Andrea Fielder
- School of Nursing and Midwifery, Sansom Institute, University of South Australia, Adelaide, SA 5001, Australia
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Brown MS. Reply to 'Methadone versus morphine for treatment of neonatal abstinence syndrome: a prospective randomized clinical trial'. J Perinatol 2015; 35:892. [PMID: 26412406 DOI: 10.1038/jp.2015.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- M S Brown
- Department of Pediatrics, Eastern Maine Medical Center, Bangor, ME, USA
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Abstract
Neonatal abstinence syndrome (NAS) is reaching epidemic proportions related to perinatal use of opioids. There are many approaches to assess and manage NAS, including one we have outlined. A standardized approach is likely to reduce length of stay and variability in practice. Circumcision is a frequent, painful procedure performed in the neonatal period. The rationale for providing analgesia is presented as well as a review of methods. Pharmacogenomics and pharmacogenetics have expanded our understanding of diseases and their drug therapy. Some applications of pharmacogenomics to the neonatal period are presented, along with pediatric challenges of developmental expression of drug-metabolizing enzymes.
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Abstract
Neonatal opioid withdrawal syndrome is common due to the current opioid addiction epidemic. Infants born to women covertly abusing prescription opioids may not be identified as at risk until withdrawal signs present. Buprenorphine is a newer treatment for maternal opioid addiction and appears to result in a milder withdrawal syndrome than methadone. Initial treatment is with nonpharmacological measures including decreasing stimuli, however pharmacological treatment is commonly required. Opioid monotherapy is preferred, with phenobarbital or clonidine uncommonly needed as adjunctive therapy. Rooming-in and breastfeeding may decease the severity of withdrawal. Limited evidence is available regarding long-term effects of perinatal opioid exposure.
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Variation in treatment of neonatal abstinence syndrome in US children's hospitals, 2004-2011. J Perinatol 2014; 34:867-72. [PMID: 24921412 DOI: 10.1038/jp.2014.114] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/11/2014] [Accepted: 05/05/2014] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome experienced by opioid-exposed infants. There is no standard treatment for NAS and surveys suggest wide variation in pharmacotherapy for NAS. Our objective was to determine whether different pharmacotherapies for NAS are associated with differences in outcomes and to determine whether pharmacotherapy and outcome vary by hospital. STUDY DESIGN We used the Pediatric Health Information System Database from 2004 to 2011 to identify a cohort of infants with NAS requiring pharmacotherapy. Mixed effects hierarchical negative binomial models evaluated the association between pharmacotherapy and hospital with length of stay (LOS), length of treatment (LOT) and hospital charges, after adjusting for socioeconomic variables and comorbid clinical conditions. RESULT Our cohort included 1424 infants with NAS from 14 children's hospitals. Among hospitals in our sample, six used morphine, six used methadone and two used phenobarbital as primary initial treatment for NAS. In multivariate analysis, when compared with NAS patients initially treated with morphine, infants treated with methadone had shorter LOT (incidence rate ratio (IRR) = 0.55; P < 0.0001) and LOS (IRR = 0.60; P < 0.0001). Phenobarbital as a second-line agent was associated with increased LOT (IRR = 2.09; P<0.0001), LOS (IRR = 1.78; P < 0.0001) and higher hospital charges (IRR = 1.84; P < 0.0001). After controlling for case-mix, hospitals varied in LOT, LOS and hospital charges. CONCLUSION We found variation in hospital in treatment for NAS among major US children's hospitals. In analyses controlling for possible confounders, methadone as initial treatment was associated with reduced LOT and hospital stay.
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Abstract
The incidence of neonatal abstinence syndrome (NAS) has increased dramatically during the past 15 years, likely due to an increase in antepartum maternal opiate use. Optimal care of these patients is still controversial because of the available published literature lacking sufficient sample size, placebo control, and comparative pharmacologic trials. Primary treatment for NAS consists of opioid replacement therapy with either morphine or methadone. Paregoric and tincture of opium have been abandoned because of relative safety concerns. Buprenorphine is emerging as a treatment option with promising initial experience. Adjunctive agents should be considered for infants failing treatment with opioid monotherapy. Traditionally, phenobarbital has been used as adjunctive therapy; however, results of clonidine as adjunctive therapy for NAS appear to be beneficial. Future directions for research in NAS should include validating a simplified scoring tool, conducting comparative studies, exploring home management options, and optimizing management through pharmacogenomics.
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Affiliation(s)
- Anita Siu
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey ; Jersey Shore University Medical Center, Neptune, New Jersey
| | - Christine A Robinson
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey ; Morristown Medical Center, Morristown, New Jersey
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Bagley SM, Wachman EM, Holland E, Brogly SB. Review of the assessment and management of neonatal abstinence syndrome. Addict Sci Clin Pract 2014; 9:19. [PMID: 25199822 PMCID: PMC4166410 DOI: 10.1186/1940-0640-9-19] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 09/03/2014] [Indexed: 12/22/2022] Open
Abstract
Neonatal abstinence syndrome (NAS) secondary to in-utero opioid exposure is an increasing problem. Variability in assessment and treatment of NAS has been attributed to the lack of high-quality evidence to guide management of exposed neonates. This systematic review examines available evidence for NAS assessment tools, nonpharmacologic interventions, and pharmacologic management of opioid-exposed infants. There is limited data on the inter-observer reliability of NAS assessment tools due to lack of a standardized approach. In addition, most scales were developed prior to the prevalent use of prescribed prenatal concomitant medications, which can complicate NAS assessment. Nonpharmacologic interventions, particularly breastfeeding, may decrease NAS severity. Opioid medications such as morphine or methadone are recommended as first-line therapy, with phenobarbital or clonidine as second-line adjunctive therapy. Further research is needed to determine best practices for assessment, nonpharmacologic intervention, and pharmacologic management of infants with NAS in order to improve outcomes.
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Affiliation(s)
- Sarah Mary Bagley
- Section of General Internal Medicine, Boston University School of Medicine, 801 Mass Ave, 2nd Floor, Boston, MA 02118, USA.
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Abstract
There is little empirical evidence that guides management of infants with neonatal abstinence syndrome. The standard of care first described in the 1970s is still prevalent today, although it has never been tested in this population. Standard of care interventions include decreasing external stimulation, holding, nonnutritive sucking, swaddling, pressure/rubbing, and rocking. These interventions meet the goals of nonpharmacologic interventions, which are to facilitate parental attachment and decrease external stimuli. Many nursing interventions used in infants with neonatal abstinence syndrome have been tested in low-birth-weight infants, whose treatment often includes the same goals. Those interventions include music therapy, kangaroo care, massage, and use of nonoscillating water beds. Nursing attitude has also been shown to be impactful on parental attachment. The American Academy of Pediatrics recommends breast-feeding in infants whose mothers are on methadone who do not have any other contraindication. It also provides guidelines for pharmacologic management but cannot provide specific recommendations about a standard first dose, escalation, or weaning schedule. Buprenorphine has some evidence about its safety in newborns with neonatal abstinence syndrome, but high-powered studies on its efficacy are currently lacking. There are many opportunities for both evidence-based projects and nursing research projects in this population.
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Singh R, Visintainer PF. Adjunctive therapy for neonatal abstinence syndrome: why not personalize it for each infant based on their in-utero exposure? J Perinatol 2014; 34:575-6. [PMID: 24968905 DOI: 10.1038/jp.2014.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- R Singh
- 1] Division of Neonatology, Department of Pediatrics, Baystate Children's Hospital, Springfield, MA, USA [2] Department of Pediatrics, Tufts University School of Medicine, Boston, MA, USA
| | - P F Visintainer
- 1] Department of Epidemiology, Baystate Medical Center, Springfield, MA, USA [2] Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
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Efficacy of clonidine versus phenobarbital in reducing neonatal morphine sulfate therapy days for neonatal abstinence syndrome. A prospective randomized clinical trial. J Perinatol 2013; 33:954-9. [PMID: 23949834 DOI: 10.1038/jp.2013.95] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 07/11/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the efficacy of clonidine versus phenobarbital in reducing morphine sulfate treatment days for neonatal abstinence syndrome (NAS). STUDY DESIGN Prospective, non-blinded, block randomized trial at a single level III NICU (Neonatal Intensive Care Unit). Eligible infants were treated with a combination of medications as per protocol. Primary outcome was treatment days with morphine sulfate. Secondary outcomes were the mean total morphine sulfate dose, outpatient phenobarbital days, adverse events and treatment failures. RESULTS A total of 82 infants were eligible, of which 68 were randomized with 34 infants in each study group. Adjusting for covariates phenobarbital as compared with clonidine had shorter morphine sulfate treatment days (-4.6, 95% confidence interval (CI): -0.3, -8.9; P=0.037) with no difference in average morphine sulfate total dose (1.1 mg kg(-1), 95% CI: -0.1, 2.4; P=0.069). Post-discharge phenobarbital was continued for an average of 3.8 months (range 1 to 8 months). No other significant differences were noted. CONCLUSION Phenobarbital as adjunct had clinically nonsignificant shorter inpatient but significant overall longer therapy time as compared with clonidine.
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Abstract
Most infants at risk for neonatal abstinence syndrome have opioid plus another drug exposure; polypharmacy is the rule rather than the exception. Scales for evaluation of neonatal abstinence syndrome are primarily based for opioid withdrawal. A standard protocol to treat neonatal abstinence syndrome has not been developed. Institute nonpharmacologic strategies for all neonates at risk. The American Academy of Pediatrics recommends mechanism-directed therapy (treat opioid withdrawal with an opioid) as the first-line therapy. Second-line medications are currently under evaluation.
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Affiliation(s)
- Kendra Grim
- Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55902, USA
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Sullivan MC, Miller RJ, Fontaine LA, Lester B. Refining Neurobehavioral Assessment of the High-Risk Infant Using the NICU Network Neurobehavioral Scale. J Obstet Gynecol Neonatal Nurs 2013; 41:17-23. [PMID: 22834719 DOI: 10.1111/j.1552-6909.2011.01322.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Nurses caring for high-risk infants use advanced assessment skills to identify the nature of infant instability and to assure timely intervention. The NICU Network Neurobehavioral Scale (NNNS) is a comprehensive assessment of neurological integrity and behavioral function of infants at risk. Research evidence supports its validity and reliability for clinical and research use. The NNNS offers nurses a neurobehavioral assessment especially suited to high-risk and premature infants.
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Affiliation(s)
- Mary C Sullivan
- professor in the College of Nursing, University of Rhode Island, Kingston, RI and a research scientist at the Brown Center for Children at Risk, Women & Infants Hospital, Providence, RI..
| | - Robin J Miller
- research scientist at the Brown Center for Children at Risk, Women & Infants Hospital, Providence, RI
| | - Lynne Andreozzi Fontaine
- professor in the Department of Psychology, Community College of Rhode Island and a research scientist at the Brown Center for Children at Risk, Women & Infants Hospital, Providence, RI
| | - Barry Lester
- Barry Lester, PhD, is a professor of psychiatry and human behavior and professor of pediatrics in the Alpert Medical School, Brown University and director of the Brown Center for the Study of Children at Risk, Women & Infants Hospital, Providence, RI
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Coyle MG, Salisbury AL, Lester BM, Jones HE, Lin H, Graf-Rohrmeister K, Fischer G. Neonatal neurobehavior effects following buprenorphine versus methadone exposure. Addiction 2012; 107 Suppl 1:63-73. [PMID: 23106928 PMCID: PMC4337995 DOI: 10.1111/j.1360-0443.2012.04040.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 09/25/2011] [Indexed: 01/06/2023]
Abstract
AIM To determine the effects of in utero exposure to methadone or buprenorphine on infant neurobehavior. DESIGN Three sites from the Maternal Opioid Treatment: Human Experimental Research (MOTHER) study, a double-blind, double-dummy, randomized clinical trial participated in this substudy. SETTING Medical Centers that provided comprehensive maternal care to opioid-dependent pregnant women in Baltimore, MD, Providence, RI and Vienna, Austria. PARTICIPANTS Thirty-nine full-term infants. MEASUREMENTS The Neonatal Intensive Care Unit (NICU) Network Neurobehavioral Scale (NNNS) was administered to a subgroup of infants on postpartum days 3, 5, 7, 10, 14-15 and 28-30. FINDINGS While neurobehavior improved for both medication conditions over time, infants exposed in utero to buprenorphine exhibited fewer stress-abstinence signs (P < 0.001), were less excitable (P < 0.001) and less over-aroused (P < 0.01), exhibited less hypertonia (P < 0.007), had better self-regulation (P < 0.04) and required less handling (P < 0.001) to maintain a quiet alert state relative to in utero methadone-exposed infants. Infants who were older when they began morphine treatment for withdrawal had higher self-regulation scores (P < 0.01), and demonstrated the least amount of excitability (P < 0.02) and hypertonia (P < 0.02) on average. Quality of movement was correlated negatively with peak NAS score (P < 0.01), number of days treated with morphine for NAS (P < 0.01) and total amount of morphine received (P < 0.03). Excitability scores were related positively to total morphine dose (P < 0.03). CONCLUSION While neurobehavior improves during the first month of postnatal life for in utero agonist medication-exposed neonates, buprenorphine exposure results in superior neurobehavioral scores and less severe withdrawal than does methadone exposure.
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Affiliation(s)
- Mara G Coyle
- Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
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Abstract
Opioid use in pregnant women has increased over the last decade. Following birth, infants with in utero exposure demonstrate signs and symptoms of withdrawal known as the neonatal abstinence syndrome (NAS). Infants express a spectrum of disease, with most requiring the administration of pharmacologic therapy to ensure proper growth and development. Treatment often involves prolonged hospitalization. There is a general lack of high-quality clinical trial data to guide optimal therapy, and significant heterogeneity in treatment approaches. Emerging trends in the treatment of infants with NAS include the use of sublingual buprenorphine, transition to outpatient therapy, and pharmacogenetic risk stratification.
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Affiliation(s)
- Walter K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, 1170 Main Building, 132 South 10th Street, Philadelphia, PA 19107, USA.
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Abstract
Opioid dependence in the setting of pregnancy provides a distinct set of challenges for providers. Treatment plans must take into consideration psychiatric and medical comorbidities while balancing risks and benefits for the maternal-fetal dyad. Treatment is best offered through a comprehensive treatment program designed to effectively deliver opioid agonist maintenance treatment along with psychosocial and obstetric care. As misuse of prescription analgesics increases in the United States, identification of the problem in pregnancy will become more important because this misuse is expected to lead to an increased prevalence of opioid dependence in pregnancy. Buprenorphine as maintenance treatment of opioid dependence during pregnancy has promise and may offer some benefits, but more research is needed, especially regarding induction of actively addicted women during pregnancy. For the present, methadone maintenance remains the standard of care for agonist treatment of opioid dependence in pregnancy against which other treatments must be compared.
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Affiliation(s)
- Jessica L Young
- Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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Raith W, Kutschera J, Müller W, Urlesberger B. Active Ear Acupuncture Points in Neonates with Neonatal Abstinence Syndrome (NAS). THE AMERICAN JOURNAL OF CHINESE MEDICINE 2012; 39:29-37. [DOI: 10.1142/s0192415x11008622] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of the study was to determine the presence of acupuncture ear points in neonates with Neonatal Abstinence Syndrome (NAS). NAS occurs in the first days of life in neonates whose mothers have a history of drug abuse, and may also occur in neonates whose mothers are currently following substitution therapy. The patients are neonates with NAS admitted over one year to the Division of Neonatology at the University Hospital Graz. The examination took place on the third day after delivery (mean value 70.3 hours) and was performed by a neuronal pen (PS 3 © Silberbauer, Vienna, Austria). An integrated sound and optical signal detected the active ear points that were then placed on an ear map. We investigated six neonates (four male, two female). All investigated neonates showed the presence of active ear acupuncture points. The psychovegetative rim was the most common organic area of the children, following by a few organic points. This corresponds with the results found in healthy neonates. In all neonates with NAS, we found the presence of psychic ear points. The identified psychic ear points are the frustration-point, R-point and the psychotropic area nasal from the incisura intertragica. In all neonates with NAS, active organic and psychic ear points were detectable in both ears. In the future, it could be possible to use active ear points for diagnostic and therapeutic purposes.
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Affiliation(s)
- Wolfgang Raith
- Research Group for Paediatric Traditional Chinese Medicine, Medical University of Graz, Austria
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
| | - Jörg Kutschera
- Research Group for Paediatric Traditional Chinese Medicine, Medical University of Graz, Austria
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
| | - Wilhelm Müller
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
| | - Berndt Urlesberger
- Research Group for Paediatric Traditional Chinese Medicine, Medical University of Graz, Austria
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
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Abstract
PURPOSE OF REVIEW This review will discuss the complex nature of maternal and other factors that can affect the infant's display of neonatal abstinence syndrome (NAS), clinical presentation and treatment of NAS, and the impact of recent findings on future directions for research. RECENT FINDINGS NAS has traditionally been described as a constellation of signs/symptoms displayed by the neonate upon withdrawal of gestational opioid exposure; however, recent research has advanced our understanding of this disorder. Other psychoactive substances, such as increasingly prescribed serotonin reuptake inhibitors, may produce an independent or synergistic discontinuation syndrome. The wide variability in NAS presentation has generated interest in the interplay of prenatal and postnatal environmental and genetic factors that may moderate or mediate its expression. Finally, recent advances in the treatment of opioid-dependent pregnant women have suggested buprenorphine as an alternative treatment to methadone during pregnancy, largely due to reduced NAS severity in exposed neonates. SUMMARY Physicians should be aware of the complexity of the maternal, fetal, and infant factors that combine to create the infant's display of NAS, and incorporate these aspects into comprehensive assessment and care of the dyad. Further research regarding the pathophysiology and treatment of NAS is warranted.
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Abstract
Maternal use of certain drugs during pregnancy can result in transient neonatal signs consistent with withdrawal or acute toxicity or cause sustained signs consistent with a lasting drug effect. In addition, hospitalized infants who are treated with opioids or benzodiazepines to provide analgesia or sedation may be at risk for manifesting signs of withdrawal. This statement updates information about the clinical presentation of infants exposed to intrauterine drugs and the therapeutic options for treatment of withdrawal and is expanded to include evidence-based approaches to the management of the hospitalized infant who requires weaning from analgesics or sedatives.
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Metz V, Köchl B, Fischer G. Should pregnant women with substance use disorders be managed differently? ACTA ACUST UNITED AC 2012; 2:29-41. [PMID: 23243466 DOI: 10.2217/npy.11.74] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pregnant women with substance use disorders have multiple special needs, which might be best managed within a multiprofessional treatment setting involving medical, psychological and social care. Adequate treatment provision remains a challenge for healthcare professionals, who should undergo special training and education when working with this patient population. Careful assessment and screening is necessary to tailor interventions individually to the woman's needs in order to achieve beneficial clinical outcomes for mothers and newborns, whereas the choice of treatment options highly depends on the type of substance of abuse and evidence-based treatment interventions available. Economic considerations have shown that early multiprofessional treatment might yield better clinical outcomes and save healthcare costs over the lifespan.
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Affiliation(s)
- Verena Metz
- Department of Psychiatry & Psychotherapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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47
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Abstract
Although a statement on Neonatal Drug Withdrawal was published in 1998 by the American Academy of Pediatrics, pharmacologic management of neonatal abstinence syndrome (NAS) remains a challenge. Published clinical trials are limited, restricting treatment decision making to practitioner's experience and preference rather than evidence-based medicine. To optimize withdrawal symptom prevention, drug selection is often based on the offending agent (opioids versus polysubstance exposure), clinical presentation, mechanism of action (agonist versus partial agonist/antagonist, receptor effects), pharmacokinetic parameters and available drug formulations. This review addresses risk factors and pathophysiology of NAS, summarizes parameters of common drugs used for the management of NAS, and reviews published literature of standard therapies as well as newer agents. Based on the current literature, paregoric is no longer recommended and oral morphine solutions remain the mainstay of therapy for opiate withdrawal. Other potential therapies include methadone, buprenorphine, phenobarbital and clonidine with the latter two agents as adjunctive therapies.
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Pharmacological treatment of neonatal opiate withdrawal: between the devil and the deep blue sea. Int J Pediatr 2011; 2011:935631. [PMID: 21760818 PMCID: PMC3133472 DOI: 10.1155/2011/935631] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 02/18/2011] [Accepted: 03/28/2011] [Indexed: 11/17/2022] Open
Abstract
Illicit drug use with opiates in pregnancy is a major global health issue with neonatal withdrawal being a common complication. Morphine is the main pharmacological agent administered for the treatment of neonatal withdrawal. In the past, morphine has been considered by and large inert in terms of its long-term effects on the central nervous system. However, recent animal and clinical studies have demonstrated that opiates exhibit significant effects on the growing brain. This includes direct dose-dependent effects on reduction in brain size and weight, protein, DNA, RNA, and neurotransmitters—possibly as a direct consequence of a number of opiate-mediated systems that influence neural cell differentiation, proliferation, and apoptosis. At this stage, we are stuck between the devil and the deep blue sea. There are no real alternatives to pharmacological treatment with opiates and other drugs for neonatal opiate withdrawal and opiate addiction in pregnant women. However, pending further rigorous studies examining the potential harmful effects of opiate exposure in utero and the perinatal period, prolonged use of these agents in the neonatal period should be used judiciously, with caution, and avoided where possible.
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Kraft WK, Dysart K, Greenspan JS, Gibson E, Kaltenbach K, Ehrlich ME. Revised dose schema of sublingual buprenorphine in the treatment of the neonatal opioid abstinence syndrome. Addiction 2011; 106:574-80. [PMID: 20925688 PMCID: PMC3022999 DOI: 10.1111/j.1360-0443.2010.03170.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS More than half of infants exposed to opioids in utero develop neonatal abstinence syndrome (NAS) of severity to require pharmacological therapy. Current treatments are associated with prolonged hospitalization. We sought to optimize the dose of sublingual buprenorphine in the treatment of NAS. DESIGN Randomized, Phase 1, open-label, active-control clinical trial comparing sublingual buprenorphine to oral morphine. SETTING Large, urban, tertiary care hospital. PARTICIPANTS Twenty-four term infants requiring pharmacological treatment for NAS. MEASUREMENTS Outcomes were neonatal safety, length of treatment and length of hospitalization. FINDINGS Sublingual buprenorphine was safe and effective. Infants treated with buprenorphine had a 23-day length of treatment compared to 38 days for those treated with morphine (P = 0.01), representing a 40% reduction. Length of hospital stay in the buprenorphine group was reduced 24%, from 42 to 32 days (P = 0.05). CONCLUSIONS Sublingual buprenorphine was safe in NAS, with a substantial efficacy advantage over standard of care therapy with oral morphine.
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Affiliation(s)
- Walter K. Kraft
- Department of Pharmacology and Experimental Therapeutics, Jefferson Medical College, Philadelphia
| | - Kevin Dysart
- Department of Pediatrics, Jefferson Medical College, Philadelphia
,A.I. DuPont Hospital for Children, Wilmington, DE
| | - Jay S. Greenspan
- Department of Pediatrics, Jefferson Medical College, Philadelphia
,A.I. DuPont Hospital for Children, Wilmington, DE
| | - Eric Gibson
- Department of Pediatrics, Jefferson Medical College, Philadelphia
,A.I. DuPont Hospital for Children, Wilmington, DE
| | - Karol Kaltenbach
- Department of Pediatrics, Jefferson Medical College, Philadelphia
| | - Michelle E. Ehrlich
- Mt. Sinai School of Medicine, New York, NY, Departments of Pediatrics and Neurology
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Abstract
The trend toward single-room neonatal intensive care units (NICUs) is increasing; however scientific evidence is, at this point, mostly anecdotal. This is a critical time to assess the impact of the single-room NICU on improving medical and neurobehavioral outcomes of the preterm infant. We have developed a theoretical model that may be useful in studying how the change from an open-bay NICU to a single-room NICU could affect infant medical and neurobehavioral outcome. The model identifies mediating factors that are likely to accompany the change to a single-room NICU. These mediating factors include family centered care, developmental care, parenting and family factors, staff behavior and attitudes, and medical practices. Medical outcomes that plan to be measured are sepsis, length of stay, gestational age at discharge, weight gain, illness severity, gestational age at enteral feeding, and necrotizing enterocolitis (NEC). Neurobehavioral outcomes include the NICU Network Neurobehavioral Scale (NNNS) scores, sleep state organization and sleep physiology, infant mother feeding interaction scores, and pain scores. Preliminary findings on the sample of 150 patients in the open-bay NICU showed a "baseline" of effects of family centered care, developmental care, parent satisfaction, maternal depression, and parenting stress on the neurobehavioral outcomes of the newborn. The single-room NICU has the potential to improve the neurobehavioral status of the infant at discharge. Neurobehavioral assessment can assist with early detection and therefore preventative intervention to maximize developmental outcome. We also present an epigenetic model of the potential effects of maternal care on improving infant neurobehavioral status.
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Affiliation(s)
- Barry M Lester
- Brown Center for Study of Children at Risk, Providence, RI 02905, USA.
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