Neonatal Abstinence Syndrome and Ethical Approaches to the Identification of Pregnant Women Who Use Drugs

Reconsidering the use of urine drug testing in reproductive settings

The urine drug test is ubiquitous within reproductive healthcare settings. Although the test can have evidence-based use for a patient and clinician, in practice, it is often applied in ways that are driven by bias and stigma, do not correctly inform decisions about clinical aspects of patient care, and cause devastating ripple effects through social and legal systems. This paper proposes a framework of guiding questions to prompt reflection on (1) the question the clinical team is trying to answer, (2) whether a urine drug test answers the question at hand, (3) how testing benefits compare with the associated risks, (4) a more effective tool for clinical decision-making if the urine drug test does not meet the standards for use, and (5) individual and institutional biases affecting decision-making. We demonstrate the use of this framework using 3 common uses of the urine drug test within abortion care and labor and delivery settings.

Disparities in Maternal-Infant Drug Testing, Social Work Assessment, and Custody at 5 Hospitals

OBJECTIVE

To evaluate for disparities in peripartum toxicology testing among maternal-infant dyads across a hospital network and subsequent child protective services (CPS) involvement.

METHODS

Retrospective chart review of 59,425 deliveries at 5 hospitals in Massachusetts between 2016 and 2020. We evaluated associations between maternal characteristics, toxicology testing, and child welfare involvement with disproportionality risk ratios and hierarchical logistical regression.

RESULTS

Toxicology testing was performed on 1959 (3.3%) dyads. Younger individuals and individuals of color were more likely to be tested for cannabis use or maternal medical complications compared to white non-Hispanic individuals. Among those without a substance use disorder, age <25 (adjusted odds ratio [aOR] 2.81; 95% confidence interval [CI], 2.43-3.26), race and ethnicity (non-Hispanic Black (aOR 1.80; 95% CI, 1.52-2.13), Hispanic (aOR 1.23; 95% CI, 1.05-1.45), mixed race/other (aOR 1.40; 95% CI, 1.04, 1.87), unavailable race (aOR 1.92; 95% CI, 1.32-2.79), and public insurance (Medicaid [aOR 2.61; 95% CI, 2.27-3.00], Medicare [aOR 13.76; 95% CI, 9.99-18.91]) had increased odds of toxicology testing compared to older, white non-Hispanic, and privately insured individuals. The disproportionality ratios in testing were greater than 1.0 for individuals under 25 years old (3.8), Hispanic individuals (1.6), non-Hispanic Black individuals (1.8), individuals of other race (1.2), unavailable race (1.8), and individuals with public insurance (Medicaid 2.6; Medicare 10.6). Among dyads tested, race and ethnicity was not associated with CPS involvement.

CONCLUSIONS

Peripartum toxicology testing is disproportionately performed on non-white, younger, and poorer individuals and their infants, with cannabis use and medical complications prompting testing more often for patients of color than for white non-Hispanic individuals.

Incidence of Newborn Drug Testing and Variations by Birthing Parent Race and Ethnicity Before and After Recreational Cannabis Legalization

IMPORTANCE

Thirty-seven US states and the District of Columbia mandate reporting newborns with suspected prenatal substance exposure to the state, and punitive policies that link prenatal substance exposure to newborn drug testing (NDT) may lead to disproportionate reporting of Black parents to Child Protective Services. The impact of recreational cannabis legalization on racial disproportionality in NDT is unknown.

OBJECTIVES

To examine variations in the incidence and results of NDT by birthing parent race and ethnicity, variables associated with variation, and changes after statewide legalization of recreational cannabis.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted from 2014 to 2020 with 26 366 live births to 21 648 birthing people who received prenatal care at an academic medical center in the Midwestern United States. Data were analyzed from June 2021 to August 2022.

EXPOSURES

Variables included birthing parent age, race, ethnicity, marital status, zip code, insurance type, prenatal and newborn diagnoses codes, and prenatal urine drug test orders and results.

MAIN OUTCOME AND MEASURES

The primary outcome was an NDT order. Secondary outcomes were substances detected.

RESULTS

Among 26 366 newborns of 21 648 birthing people (mean [SD] age at delivery, 30.5 [5.2] years), most birthing parents were White (15 338 [71.6%]), were non-Hispanic (20 125 [93.1%]), and had private insurance coverage (16 159 [74.8%]). The incidence of NDT ordering was 4.7% overall (1237 newborns). Clinicians ordered more NDTs for Black compared with White newborns (207 of 2870 [7.3%] vs 335 of 17 564 [1.9%]; P < .001) when the birthing parent had no prenatal urine drug test, a presumably low-risk group. Overall, 471 of 1090 NDTs (43.3%) were positive for only tetrahydrocannabinol (THC). NDTs were more likely to be positive for opioids in White compared with Black newborns (153 of 693 [22.2%] vs 29 of 308 [9.4%]; P < .001) and more likely to be positive for THC in Black compared with White newborns (207 of 308 [67.2%] vs 359 of 693 [51.8%]; P < .001). Differences remained consistent after state recreational cannabis legalization in 2018. Newborn drug tests were more likely to be positive for THC after legalization vs before legalization (248 of 360 [68.9%] vs 366 of 728 [50.3%]; P < .001) with no significant interaction with race and ethnicity groups.

CONCLUSIONS AND RELEVANCE

In this study, clinicians ordered NDTs more frequently for Black newborns when no drug testing was done during pregnancy. These findings call for further exploration of how structural and institutional racism contribute to disproportionate testing and subsequent Child Protective Services investigation, surveillance, and criminalization of Black parents.

Disparities in opioid use disorder-related hospital use among postpartum Virginia Medicaid members

INTRODUCTION

The overdose crisis is increasingly revealing disparities in opioid use disorder (OUD) outcomes by race and ethnicity. Virginia, like other states, has witnessed drastic increases in overdose deaths. However, research has not described how the overdose crisis has impacted pregnant and postpartum Virginians. We report the prevalence of OUD-related hospital use during the first year postpartum among Virginia Medicaid members in the years preceding the COVID-19 pandemic. We secondarily assess how prenatal OUD treatment is associated with postpartum OUD-related hospital use.

METHODS

This population-level retrospective cohort study used Virginia Medicaid claims data for live infant deliveries between July 2016 and June 2019. The primary outcome of OUD-related hospital use included overdose events, emergency department visits, and acute inpatient stays. Independent variables of interest were prenatal receipt of medication for OUD (MOUD) and receipt of non-MOUD treatment components in line with a comprehensive care approach (e.g., case management, behavioral health). Both descriptive and multivariate analyses were performed for all deliveries and stratified by White and Black non-Hispanic individuals to bring attention to the devastating impacts of the overdose crisis within communities of color.

RESULTS

The study sample included 96,649 deliveries. Over a third were by Black birthing individuals (n = 34,283). Prenatally, 2.5 % had evidence of OUD, which occurred more often among White (4 %) than Black (0.8 %) non-Hispanic birthing individuals. Postpartum OUD-related hospital use occurred in 10.7 % of deliveries with OUD, more commonly after deliveries by Black, non-Hispanic birthing individuals with OUD (16.5 %) than their White, non-Hispanic counterparts (9.7 %), and this disparity persisted in the multivariable analysis (Black AOR 1.64, 95 % CI 1.14-2.36). Postpartum OUD-related hospital events were less frequent for individuals receiving versus not receiving postpartum MOUD within 30 days prior to the event. Prenatal OUD treatment, including MOUD, was not associated with decreased odds of postpartum OUD-related hospital use in the race-stratified models.

CONCLUSION

Postpartum individuals with OUD are at high risk for mortality and morbidity, especially Black individuals not receiving MOUD after delivery. An urgent need remains to effectively address the systemic and structural drivers of racial disparities in transitions of OUD care through the one-year postpartum period.

Intrauterine and Neonatal Exposure to Opioids: Toxicological, Clinical, and Medico-Legal Issues

Opioids have a rapid transplacental passage (i.e., less than 60 min); furthermore, symptoms characterize the maternal and fetal withdrawal syndrome. Opioid withdrawal significantly impacts the fetus, inducing worse outcomes and a risk of mortality. Moreover, neonatal abstinence syndrome (NAS) follows the delivery, lasts up to 10 weeks, and requires intensive management. Therefore, the prevention and adequate management of NAS are relevant public health issues. This review aims to summarize the most updated evidence in the literature regarding toxicological, clinical, and forensic issues of intrauterine exposure to opioids to provide a multidisciplinary, evidence-based approach for managing such issues. Further research is required to standardize testing and to better understand the distribution of opioid derivatives in each specimen type, as well as the clinically relevant cutoff concentrations in quantitative testing results. A multidisciplinary approach is required, with obstetricians, pediatricians, nurses, forensic doctors and toxicologists, social workers, addiction specialists, and politicians all working together to implement social welfare and social services for the baby when needed. The healthcare system should encourage multidisciplinary activity in this field and direct suspected maternal and neonatal opioid intoxication cases to local referral centers.

Public Health Nurses' Activities toward Child Abuse Prevention before Childbirth in Japan

As child abuse becomes increasingly serious, the activities of nursing professionals during pregnancy have become more important. This study aimed to describe public health nurses' (PHNs) activities for child abuse prevention, focusing on how they approach pregnant women at possible risk to enable early prevention. A qualitative design was applied. Fifteen PHNs in Japan participated and were interviewed about 23 cases using semistructured interviews focus on the series of PHN's activity. Transcripts were coded, and the codes were categorized into several categories, and content analysis was conducted. PHNs' activities included exploring at-risk cases by various means, creating opportunities to begin individual support, examining the risk of abuse specifically to predict suspected abuse after childbirth, encouraging behavior to reduce the risk of abuse, waiting consciously for a while, expanding support systems for cases. If PHNs anticipated that the situation would not stabilize, they returned to creating an opportunity to begin individual support and repeated the process. PHNs' had six activities, which were repeated depending on the magnitude of the risk of abuse. It was suggested that these activities are aimed at long-term child-rearing support. PHNs belonging to municipal governments conducted these activities; further support can be provided by utilizing municipal governments.

Urine drug screening on labor and delivery

BACKGROUND

Substance use including opioids, methamphetamines, benzodiazepines, and barbiturates during pregnancy is harmful for the pregnant person and the fetus. Routine screening using validated questionnaires is recommended, but often biologic sampling is done instead. There is often bias in urine drug screening on labor and delivery units.

OBJECTIVE

This study aimed to compare characteristics of people who did and did not receive urine drug screening during labor and delivery and to examine the relationship of maternal results to neonatal results.

STUDY DESIGN

This was a retrospective chart review examining all people in 2017 who delivered in the labor and delivery unit at our institution. We collected urine drug screening result information, maternal demographic data, follow-up after positive maternal tests, and neonatal test results. Individual characteristics and obstetrical outcomes were analyzed.

RESULTS

Of 6265 deliveries, 297 urine drug screening tests were ordered. People who were tested identified most commonly as Native Hawaiian or Pacific Islander (P<.0001). The most common indications for ordering tests were a history of substance use and insufficient prenatal care (P<.0001). People who tested positive were more likely to self-identify as White (P=.03) and have history of substance use (P<.0001). Among the positive test results, 24 (24%) were caused by a provider-ordered medication. Self-identification as Native Hawaiian or Pacific Islander was not predictive of a positive result. Of the tested people, 36% (108/297) had a positive result on preliminary testing, and 33% (98/295) on confirmatory testing.

CONCLUSION

Native Hawaiians and Pacific Islanders were more likely to undergo testing, whereas White people were more likely to have a positive result. Maternal results were not reliable for predicting neonatal drug test results and vice versa. With rising rates of substance use disorders in the pregnant and reproductive-age population, standardized unbiased race-neutral guidelines for urine drug screening should be implemented using laboratory test results that include preliminary and reflex confirmatory results.

Urine Drug Screening for Isolated Marijuana Use in Labor and Delivery Units

Isolated marijuana use is frequently used as an indication for urine drug screening in labor and delivery units. We aimed to identify the results of urine drug screening in a labor and delivery unit for isolated marijuana use. This retrospective cohort study reviewed data from patients admitted for delivery at an urban academic center from January 1, 2020, to December 31, 2020. Patients undergoing urine drug screening for isolated marijuana use were more likely to be younger (median age 25 vs 29 years, P <.001), more often Black (adjusted odds ratio [aOR] 2.58, 95% CI 1.94-3.41), and more likely to have public insurance (aOR 1.54, 95% CI 1.21-1.95). A few (5/338, 1.5%) urine drug screening tests performed for isolated marijuana use were positive for substances besides marijuana. Most patients (177/197, 89.8%) with a urine drug screening test result that was positive for marijuana were reported to the state child abuse hotline. The utility of isolated marijuana use as a criterion for urine drug screening thus appears limited in benefit but rife with inequitable potential to harm.

Neonatal abstinence syndrome: Effectiveness of targeted umbilical cord drug screening

OBJECTIVE

This study sought to determine if targeted drug screening of newborns was effective in identifying a positive drug test result.

STUDY DESIGN

This was a retrospective cross-sectional study. A total of 340 infants met criteria for drug screening. Sensitivity and specificity were used to evaluate each of the potential risk factors in terms of their ability to predict a positive drug test result. Two-sample t-tests were used to compare differences in Finnegan scores between babies with a positive drug test result and those with a negative one.

RESULT

The risk factor with the highest sensitivity was maternal history of drug use. The difference in the Finnegan scores between groups was statistically significant.

CONCLUSION

The risk factors associated with this study were not very sensitive. The only way to identify all infants at risk of NAS is to standardize the screening process and apply to all infants.

Informed consent is poorly documented when obtaining toxicology testing at delivery in a Massachusetts cohort

BACKGROUND

Positive toxicology testing at delivery can have enormous consequences for birthing persons and their families, including charges of child abuse or neglect and potential loss of custody for the birthing parent. Therefore state and national guidelines stipulate that, clinicians must obtain consent before toxicology testing at delivery.

OBJECTIVE

This study aimed (1) to determine clinician documentation of patient consent for peripartum toxicology testing and (2) to characterize the extent to which patient and hospital characteristics were associated with documented consent.

STUDY DESIGN

This was a retrospective cohort of individuals who underwent toxicology testing within 96 hours of delivery between April 2016 and April 2020 at 5 affiliated hospitals across Massachusetts. Medical records were reviewed for documentation of clinician intent to obtain maternal toxicology, testing indication, verbal consent to testing, and child protective services involvement. Hierarchical multivariable logistic regression was used to examine the association between patient and hospital characteristics and documentation of verbal consent.

RESULTS

Among 60,718 deliveries, 1562 maternal toxicology tests were obtained. Verbal consent for testing was documented in 466 cases (29.8%). Documented consent was lacking across most demographic groups. Consent was no more likely to be documented when a report was filed with child protective services and less likely in cases where the birthing parent lost custody before discharge (P=.003). In our multivariable model, consent was least likely to be documented when a maternal complication (abruption, hypertension, preterm labor, preterm premature rupture of membranes, or intrauterine fetal demise) was the indication for testing (adjusted odds ratio, 0.46; 95% confidence interval, 0.28-0.76). Verbal consent was twice as likely to be documented in delivery hospitals with established consent policies (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.37).

CONCLUSION

Consent for toxicology testing at delivery seemed to be infrequently obtained on the basis of clinician documentation. Provider education and hospital policies for obtaining informed consent are needed to protect the rights of birthing individuals.

Motherhood, pregnancy and gateways to intervene in substance use disorder

Motherhood increases women's use of health and social services, presenting opportunities to identify and refer women with substance use disorder (SUD) to treatment. We pooled 4 years (2015-2018) of cross-sectional data from National Survey on Drug Use and Health on women of child-bearing age (18-44) in the United States (n = 64,346). (1) We compared the use of services (health, social and criminal justice involvement) by SUD and 'motherhood' (pregnant or has one or more children under 18). We used multivariable logistic regression models to estimate the association between motherhood, SUD and their interaction with the use of services. (2) We estimated the association between the use of different services and SUD treatment use among women with SUD. Among women of child-bearing age, 9.7% had SUD. Mothers who had SUD were more likely to use social services (AOR = 1.48 [95% CI: 1.22, 1.79]) and mental health services compared with non-mothers who did not have SUD (AOR = 1.40 [95% CI: 1.19, 1.65]). The following factors were associated with increased odds of receiving SUD treatment among mothers: mental health treatment utilisation (AOR = 1.94 [95% CI: 1.29, 2.93]); Medicaid coverage (AOR = 2.48 [95% CI: 1.64, 3.76]); and criminal justice involvement (AOR = 3.38 [95% CI: 1.97, 5.80]). To increase treatment access, it is important to address women's different stages in life, including how to best engage women in SUD care across different settings.

Criminalization of Care: Drug Testing Pregnant Patients

This article reveals how law and legal interests transform medicine. Drawing on qualitative interviews with medical professionals, this study shows how providers mobilize law and engage in investigatory work as they deliver care. Using the case of drug testing pregnant patients, I examine three mechanisms by which medico-legal hybridity occurs in clinical settings. The first mechanism, clinicalization, describes how forensic tools and methods are cast in clinical terminology, effectively cloaking their forensic intent. In the second, medical professionals informally rank the riskiness of illicit substances using both medical and criminal-legal assessments. The third mechanism describes how gender, race, and class inform forensic decision-making and criminal suspicion in maternal health. The findings show that by straddling both medical and legal domains, medicine conforms to the standards and norms of neither institution while also suspending meaningful rights for patients seeking care.

Cannabis Use in Pregnancy: A State of the Science Review

With a growing number of states legalizing recreational use, cannabis consumption during pregnancy is increasing. Population-based data and rigorous studies examining the association of cannabis use in pregnancy with perinatal outcomes are limited, but trends include preterm prelabor rupture of membranes, placenta previa, and an increased length of hospital stay. Neonates of pregnant persons who used cannabis during their pregnancy can be at increased risk of low birth weight, preterm birth, neonatal intensive care unit admission, neurocognitive deficits, and infectious and neurologic morbidity and mortality. This state of the science review examines the prevalence of cannabis use in pregnancy, its pharmacodynamics and how that is influenced by pregnancy, and associated adverse perinatal and neonatal outcomes. Implications for health care providers caring for pregnant persons using cannabis, especially in legalized states, are discussed.

The harms of punishing substance use during pregnancy

As rates of substance use have increased in the United States, rates of substance-involved pregnancies have also been on the rise, inspiring new civil policies designed to punish pregnant and parenting individuals who engage in substance use or are living with an untreated substance use disorder. Proponents of punitive civil policies argue that such policies will deter substance use behaviors and/or that substance use during pregnancy deserves punishment for harming the fetus. Current scientific evidence invalidates both claims, offering compelling evidence that punitive civil policies often worsen the harms of substance use for both parent and child. In this commentary, we review this evidence and explain how punitive policies that threaten child removal and the termination of parental rights exacerbate the very problems they are ostensibly designed to reduce. Rather than coercive and punitive responses, families affected by substance use need greater access to affordable, evidence-based treatment as well as services that address the structural and relational concerns underlying substance use. Above all, responses to perinatal substance use in both policy and practice should prioritize keeping families together.

Racial differences in indications for obstetric toxicology testing, and relationship of indications to test results

BACKGROUND

Despite illicit substance use in pregnancy occurring across all demographic groups, minority and lower income pregnant and delivering patients tend to undergo testing at a higher rate than their counterparts. National guidelines for indications do not exist, and ordering of toxicology testing may be applied inequitably.

OBJECTIVE

To evaluate whether any documented indications in a large cohort of patients were associated with a positive toxicology test, and whether indications for urine toxicology testing were applied consistently to different demographic groups.

STUDY DESIGN

Retrospective cohort study reviewing pregnant and delivering patients who underwent toxicology testing on obstetric units at one institution from 5/30/2015 to 12/31/2018. Age, race, marital status, median income of residential zip code, indications for testing, and test result were collected for each patient by individual chart review. Indications included preterm complications (preterm prelabor rupture of membranes or preterm labor), abruption or hypertension, reported substance use, fetal complications, maternal complications, and none. Multivariate logistic regression models were analyzed for association between indication and test result, and for likelihood of marijuana as the sole positive test result. Logistic regression was used to evaluate the relationship of indication for testing with maternal race.

RESULTS

Among 20,274 births, 551 patients underwent toxicology testing during the study period. No indication for drug toxicology testing was associated with a positive result except reported current or prior substance use. Compared to White patients, Black and Hispanic women were 4.26 (95%CI: 2.55, 7.09) and 5.75 (95%CI: 2.89, 11.43) times more likely to have toxicology testing for an indication other than reported substance use. Of all patients with positive tests (n=194), 48% tested positive for marijuana only.

CONCLUSIONS

Compared to their White counterparts, Black and Hispanic pregnant and delivering patients may be more frequently toxicology tested for indications less clearly associated with illicit substance use. Absence of evidence- based guidelines for toxicology testing on obstetrics units risks inequitable care and stigmatization of patient groups.

Within-Hospital Concordance of Opioid Exposure Diagnosis Coding in Mothers and Newborns

BACKGROUND AND OBJECTIVES

We measured within-hospital concordance of mothers with opioid use disorder (OUD) and newborns with neonatal abstinence syndrome (NAS) or opioid exposure (OE). Secondarily, we described the demographics of mothers and newborns with and without opioid-related diagnoses.

METHODS

We used hospital discharge abstracts from California, Florida, New Jersey, and Pennsylvania in 2016. Descriptive statistics were used to compare newborns and mothers with and without opioid-related diagnoses. Within-hospital frequencies of mothers with OUD and newborns with NAS and OE were compared. Pearson's correlation coefficients were calculated.

RESULTS

In 474 hospitals, we found 896 702 mothers (0.6% with OUD) and 910 867 newborns (0.47% with NAS, 0.85% with OE, and 0.07% with both). Although the frequency of mothers and newborns with opioid-related diagnoses in a hospital was strongly correlated (r = 0.81), more infants were identified than mothers in most hospitals (68.3%). Mothers with OUD were more likely to be white (79% vs 40.9%), on Medicaid (75.4% vs 44.0%), and receive care in rural hospitals (20.6% vs 17.6%), compared with mothers without OUD. Newborns with NAS had demographics similar to women with OUD. Newborns with OE were disproportionately Black (22% vs 7%) or Hispanic (22% vs 9%).

CONCLUSIONS

More newborns are diagnosed with opioid-related disorders than mothers are. Although infants diagnosed with NAS had demographics similar to mothers with OUD, infants with OE were more likely to be Black or Hispanic. The lack of diagnostic coding of maternal OUD and the racial differences in diagnoses warrant attention.

Project Console: a quality improvement initiative for neonatal abstinence syndrome in a children's hospital level IV neonatal intensive care unit

Objective

To improve care for infants with neonatal abstinence syndrome.

Design

Infants with a gestational age of ≥35 weeks with prenatal opioid exposure were eligible for our quality improvement initiative. Interventions in our Plan–Do–Study–Act cycles included physician consensus, re-emphasis on non-pharmacological treatment, the Eat Sleep Console method to measure functional impairment, morphine as needed, clonidine and alternative soothing methods for parental unavailability (volunteer cuddlers and automated sleeper beds). Pre-intervention and post-intervention outcomes were compared.

Results

Length of stay decreased from 31.8 to 10.5 days (p<0.0001) without an increase in readmissions. Composite pharmacotherapy exposure days decreased from 28.7 to 5.5 (p<0.0001). This included reductions in both morphine exposure days (p<0.0001) and clonidine exposure days (p=0.01). Fewer infants required pharmacotherapy (p=0.02).

Conclusions

Our study demonstrates how a comprehensive initiative can improve care for infants with neonatal abstinence syndrome in an open-bay or a high-acuity neonatal intensive care unit when rooming-in is not available or other comorbidities are present.

Concordance and discordance between maternal and newborn drug test results

BACKGROUND

Screening for substance use is recommended during pregnancy, and many clinicians rely on urine drug screening to identify newborns at potential risk for withdrawal.

OBJECTIVE

This study aimed to determine the concordance and discordance rates between maternal and neonatal drug testing at or near the time of delivery.

STUDY DESIGN

This retrospective chart review was performed at a single institution that employs universal testing for those who consent. Results of maternal and neonatal urine drug testing via immunoassay at delivery were compared.

RESULTS

Of 1573 singleton pregnancies, 233 mothers (14.8%) had a positive test result for any substance and 102 of their newborns (43.8%) had concordant positive test results. Of the 285 positive maternal test results for individual substances, 133 (46.7%) were concordant with newborn test results. After removing iatrogenic positives, there were 84 truly discordant pairs representing 5.9% of the total cohort of test pairs, but 29.5% of the pairs with maternal positive test results. When considering the outcome of a newborn positive test result, the overall sensitivity and specificity for the maternal test were 21.1% and 85.8%, respectively. The positive and negative predictive values were 46.7% and 96.4%, respectively. After excluding iatrogenic positive test results, the sensitivity and specificity for maternal testing were 97.8% and 99.4%, respectively, and the negative predictive value of maternal testing for all substances approached 100%. A total of 11 pairs of twins had at least 1 twin with a positive drug test result, and of these, 6 twin pairs (54.5%) had drug test results that were discordant from each other.

CONCLUSION

There is a high rate of iatrogenic discrepancy in maternal and neonatal drug testing. After adjusting for iatrogenic positive test results, the negative predictive value of maternal testing is high. Many discrepancies, such as those in twins, remained unexplained by medication administration, and potential reasons for these discrepancies warrant further investigation.

Clinical care of neonates undergoing opioid withdrawal in the immediate postpartum period

As the opioid epidemic escalates in westernized countries around the world, chronic opioid use during pregnancy has become a growing public health issue. There are increasing concerns that chronic maternal opioid use might adversely affect the developing fetal brain. Furthermore, the sudden discontinuation of the trans-placental opioid supply at birth puts newborns at acute risk for neonatal opioid withdrawal syndrome (NOWS). NOWS is a multi-system disorder that has been identified in approximately 50-80% of neonates exposed to opioids due to chronic maternal use. Clinically, NOWS affects the central and autonomic nervous systems as well as the gastrointestinal and respiratory tracts. The clinical features of NOWS include hyperirritability, high-pitched crying, restlessness, tremors, poor sleep, agitation, seizures, sweating, fever, poor feeding, regurgitation, diarrhea, and tachypnea. NOWS is currently diagnosed using a clinical scoring tool followed by toxicological confirmation of the presence of opioids in meconium or tissue specimens. The first-line treatments for NOWS are non-pharmacologic comfort measures. If these measures fail, neonates may be treated with opioids and/or sedatives. Since the severity of NOWS can be highly variable, it is quite difficult to predict which opioid-exposed neonates will require pharmacotherapy and prolonged hospitalization. Factors associated with maternal polysubstance use, including the use of illicit substances and tobacco, have been associated with the increased severity and duration of NOWS. Since neonates with NOWS are at increased risk for long-term adverse neurodevelopmental outcomes, ongoing monitoring beyond the neonatal period is essential.

Modernizing Perinatal Substance Use Management

The increase in prescription and illicit opioid use since 2000 has become an urgent public health crisis. While the opioid epidemic spans racial, regional, and socioeconomic divides, women have surfaced as one demographic affected by opioid use and related sequelae. Certain federal and state regulations, secondary to the Child Abuse Prevention and Treatment Act, strip pregnant women with opioid use disorders of the ability to engage autonomously with their health care clinician while simultaneously impeding their ability to achieve and sustain recovery. The purpose of this article is to explore current health policy that impacts pregnant women who use opioids. Recommendations to improve care, broadly, will be highlighted to include access to contraceptive services, universal screening for perinatal substance use, and access to appropriate treatment strategies. Policy modifications to facilitate these recommendations are discussed. The Centers for Disease Control and Prevention Policy Analytical Framework was utilized to derive recommendations. The recommendations are relevant to advanced practice registered nurses and midwives who have the potential to treat substance use in women, to women's health and pediatric registered nurses, and to nursing administrators who are involved in decision-making in obstetric and pediatric settings.

A mother's bond: An ecological momentary assessment study of posttraumatic stress disorder symptoms and substance craving during pregnancy

Pregnant women with substance use disorder (SUD) comprise an underserved population with complex treatment needs, including complications from trauma histories and comorbid psychological disorders. Using ecological momentary assessment, we examined momentary fluctuations in posttraumatic stress disorder (PTSD) symptoms, prenatal bonding, and substance craving, among pregnant women in SUD treatment who had a history of trauma. We hypothesized that (a) PTSD symptoms and prenatal bonding would each be associated with substance craving and (b) PTSD symptoms would be negatively associated with prenatal bonding, and this would at least partially account for the association between PTSD symptoms and substance craving (i.e., indirect effect). Participants (n = 32) were on average 27.1 weeks pregnant (SD = 5.27), 27.8 years old (SD = 4.54), and predominantly Hispanic/Latina (66%). At the within subjects level, higher momentary ratings of PTSD symptoms were associated with lower quality (but not intensity of preoccupation) of prenatal bonding, which in turn was associated with greater craving. Lower quality of prenatal bonding partially mediated the positive association between PTSD symptoms and craving, which remained strong after accounting for prenatal bonding. Our results provide some preliminary support for considering interventions aimed at stabilizing or decreasing PTSD symptoms and stabilizing or increasing prenatal bonding to reduce substance craving and, thus, the risk of perinatal substance use among women with SUD and trauma histories. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Interaction with the justice system and other factors associated with pregnant women's self-report and continuation of use of marijuana

BACKGROUND

Marijuana use in pregnancy is common and self-report of use to healthcare providers is variable. This study evaluates the relationship between prior interaction with the justice system as well as other factors associated with self-report and continuation of use of marijuana in pregnancy.

METHODS

This retrospective cohort study included women with a positive urine toxicology test for marijuana at their initial prenatal visit. Prior interaction with the judicial system was determined by querying a publicly available database. Those who did and did not self-report use were compared using chi square and Fisher's exact test for analysis of categorical variables and t test for comparison of means. A logistic regression was performed to determine factors related to remaining positive at the time of birth.

RESULTS

Of 597 women included in analysis, 308 (51.6%) self-reported use. African American women were more likely to self-report use (p = 0.02). Interaction with the justice system was not statistically predictive of self-report. Of 483 (80.9%) who had birth outcome data available, 117 (24.2%) had positive marijuana tests at the time of delivery. Women who tested positive at birth were older (27.3 v 25, p < 0.01), more likely to present later for care (p = 0.02) and more likely to have self-reported their use at their initial visit (p = 0.03).

DISCUSSION

Discrepancies exist between pregnant women's self-report of marijuana use and biologic testing results. Women with positive toxicology testing who self-report use may do so due to more problematic use and may benefit from enhanced interventions.

Pain, Opioids, and Pregnancy: Historical Context and Medical Management

Women are being disproportionately affected by the opioid crisis, including during pregnancy. Pain and other vulnerabilities to addiction differ between men and women. Management of opioid use disorder should be gender informed and accessible across the lifespan. During pregnancy, care teams should be multidisciplinary to include obstetrics, addiction, social work, anesthesia, pediatrics, and behavioral health. Pain management for women with opioid use disorder requires tailored approaches, including integration of trauma-informed care and addressing psychosocial needs. Thus, coordinated continued care by obstetric and addiction providers through pregnancy into postpartum is key to supporting women in recovery.

Interventions for the Treatment of Neonatal Abstinence Syndrome

The growing incidence of neonatal abstinence syndrome (NAS) among newborns is a public health crisis that is a sequela of the national opioid crisis. When fetuses are exposed to opioids in utero, whether through prescription pain medication, illicit substances, or supervised medication-assisted opioid treatment, neonates can experience withdrawal symptoms shortly after birth. Opioid withdrawal manifests with symptoms of central nervous system and autonomic nervous system dysfunction. Treatment of NAS begins with nonpharmacologic interventions, and if a neonate requires more intensive treatment, care will escalate to include pharmacologic treatments, including morphine, methadone, and buprenorphine. When pharmacologic therapy begins, nonpharmacologic intervention is not ceased; rather, the two are used in conjunction in an attempt to reduce the amount of medication required for successful treatment. Herein we review nonpharmacologic nursing interventions, discuss the most common pharmacologic treatments for NAS, and present practice implications for nurses who work with childbearing families.

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

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

Prenatal Substance Use and Perceptions of Parent and Partner Use Using the 4P's Plus Screener

Background Prenatal substance use screening is recommended. The 4 P's Plus screener includes questions on perceived problematic substance use in parents and partner that are not considered in risk stratification. Objectives This research examined the: (1) prevalence of self-reported problematic parental and partner substance use and associations with biochemically-verified prenatal substance use; (2) utility of self-reported perceptions of parent/partner substance use as proxies for prenatal substance use; and (3) degree to which the sensitivity of the 4P's Plus can be augmented with consideration of parent/partner questions in risk stratification. Methods A convenience sample of 500 pregnant women was recruited between January 2017 and January 2018. Participants completed the 4P's Plus and provided urine for drug testing. Diagnostic utility of problematic parent/partner substance use questions was assessed, then compared to the 4P's Plus used as designed, and to the 4P's Plus used with these 2 questions included in risk stratification. Results Half (51%) of respondents reported either partner or parental problematic substance use. When partner or parent problematic substance use were considered as proxies for prenatal substance use, sensitivity was 65% and specificity was 55%. When used as intended, sensitivity was 94% and specificity was 29%. Including partner/parent questions increased sensitivity to 96% but lowered specificity (19%). Partner substance use and combined partner/parent use were associated with prenatal substance use [adjusted odds ratio (aOR): 2.0 (1.2, 2.4; p = 0.006); aOR = 1.6 (1.1, 2.5, p = 0.04)]. Conclusions for Practice Sensitivity of the 4P's Plus may improve with inclusion of self-reported problematic partner/parent substance use items in risk stratification.

The Association Between Antenatal Maternal Self-reported Substance Use, Maternal Characteristics, and Obstetrical Variables

BACKGROUND

Substance use disorders during pregnancy are a concern both to the public and medical community, because the negative consequences can be detrimental to both mother and the fetus. The accurate identification of prenatal drug exposure is necessary to determine appropriate medical and psychosocial intervention, and to identify risk factors that may affect outcomes for the mother and her newborn. The prevalence of prenatal drug exposure is very difficult to estimate because of flaws in all methods of identification.

OBJECTIVE

The study is designed to identify risk factors and demographic variables that contribute to nondisclosure of illicit and nonillicit substance use. In addition, this study aims to determine if nondisclosure leads to adverse neonatal outcomes.

STUDY DESIGN

Newborns delivered with a positive meconium or urine toxicology, and/or known maternal exposure to illicit and nonillicit substances, were identified. Maternal records were reviewed for disclosure of substance use during pregnancy at admission for delivery along with other medical and demographic variables. Women with antenatal prescription drug use that may alter toxicology screens were excluded from analysis. Pediatric records were also reviewed to obtain neonatal variables.

RESULTS

One hundred sixty-eight newborns were identified as having prenatal exposure to an illicit or nonillicit substance over the 4-year period. Eighty-six per cent (145/168) of women tested positive or their newborn tested positive for at least 1 illicit substance, and 49% (82/168) tested positive for multiple illicit substances. Fifty-four per cent (91/168) of women did not disclose using at least one illicit drug for which she or her newborn tested positive.With regards to maternal characteristics, there was no statistically significant difference between age (P = 0.958), parity (P = 0.300), or race (P = 0.531), and disclosure or failure to disclose about illicit drug use. However, patients who did not report prenatal illicit drug use (33/82 = 40%) were less likely (P = 0.049) to receive complete prenatal care (defined as 3 or more visits) compared with those who acknowledged their substance use (40/70 = 57%).

CONCLUSION

Substance use disorders during pregnancy are an often underestimated cause of maternal, fetal, and neonatal complications. Limited studies have examined the relationship between maternal characteristics and associated illicit or nonillicit drug use. The absence of correlation between maternal demographics and disclosure of illicit substance use demonstrates the fact that all antepartum patients are at risk for these behaviors. Furthermore, the fact that women who did not disclose their illicit drug use were less likely to seek complete prenatal care reflects the need for physicians to provide a destigmatized healthcare environment, encouraging pregnant women to disclose their substance use so they can be provided with appropriate counseling and treatment.

Cigarette Smoking Status and Substance Use in Pregnancy

Objectives Substance use during pregnancy is a significant public health issue. Prenatal substance use increased in the past decade while prenatal cigarette smoking has remained stable. Co-use of tobacco and other drugs is a concern because of potential additive risks. This study aims to describe the prevalence rates of substance use among pregnant women and examine the association between smoking status (nonsmoker, recent quitter and current smoker) and other drug use. Methods In this cross-sectional study, pregnant women (n = 500) were recruited from two obstetric practices to complete three substance use screeners and have their urine tested for 12 different drug classes, including cannabis, opioids and cocaine. Participants were divided into three groups based on survey responses: nonsmokers, recent quitters (smoked in the month prior to pregnancy but not past month) and current smokers (past-month). Results Approximately 29% of participants reported smoking in the month before pregnancy. During pregnancy, 17, 12 and 71% were current smokers, recent quitters and nonsmokers respectively. Overall prevalence of illicit or prescription drug use in pregnancy was 27%. Cannabis was the most common drug used in pregnancy with prevalence of 22%, followed by opioids (4%), cocaine (1%), tricyclic antidepressants (TCAs) (1%), amphetamines (1%), and benzodiazepines (1%). On multivariable logistic regression, smoking in pregnancy was associated with a positive urine drug screen; with adjusted odds ratio (aOR) 4.7 (95% CI 2.6-8.3) for current smokers and 1.6 (95% CI 0.8-3.3) for recent quitters. Factors negatively associated with positive drug screen were second and third trimester pregnancies, 0.5 (0.3-0.9) and 0.3 (0.2-0.6) respectively; and employment, 0.5 (0.3-0.8). Conclusions for Practice Co-use of tobacco and illicit drugs, particularly cannabis, is relatively high during pregnancy. Additional research is needed to understand the health implications of co-use versus use of tobacco only. Given the strong association between smoking and other drug use, clinicians should routinely assess for illicit drug use in women who smoke during pregnancy.

Detection of opioids in umbilical cord lysates: an antibody-based rapid screening approach

In pregnancy, opioids may be used medically and also misused. We hypothesized that the umbilical cord (UC) could be a good screening tool for determining opioid exposure and improving medical care. One hundred and one UC, each with 50 associated ICD9/ICD10 codes were used. Using predictive pharmacokinetic analysis we determined that opioids could be detected since last ingestion prior to birth. The UC were lysed and screened using ELISA detecting multiple opioids and their metabolites. Statistical comparisons to obstetric and neonatal outcomes were performed. Although the commercial ELISA was less sensitive in UC than blood or urine, there was perfect method selectivity as compared to a subset of cords designated positive or negative by clinical diagnostics, so our results are accurate and reliable. Absolute quantitation was not possible because the antibody cross reacts with multiple compounds, but 'low' or 'high' levels of exposure were assigned. Prevalence of opioids was 11%, which reduced to 7% when cesarean-section births were eliminated. For non-cesarean-section infants adjusted for preterm birth, advanced maternal age and smoking (independent risk factors), opioids were significantly associated with intra-uterine growth restriction (p = 0.017) and admission to neonatal intensive care (p = 0.002). UC can be collected noninvasively and rapidly providing a reliable tools for semi-quantitative opioid screening using ELISA. Moreover, as UC are usually discarded collection presents few technical or safety concerns for staff or patients. Further development of this methodology may provide a rapid, noninvasive clinical screening tool to identify NAS and/or opioid use in late pregnancy.

Neonatal abstinence syndrome

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.

Historical and clinical factors associated with positive urine toxicology screening on labor and delivery

OBJECTIVE

Illicit drug use in pregnancy may lead to adverse outcomes. Although the American College of Obstetricians and Gynecologists recommends that all pregnant women be screened for substance use by questionnaire or conversation, it remains unclear how well these methods identify women with illicit drug use. Drug use may also be suspected based on clinical complications, such as fetal demise or placental abruption. There are currently no formal recommendations to guide targeted laboratory testing in women perceived to be at risk based on historical or clinical factors. Our objective was to determine which historical and clinical factors are associated with positive urine toxicology screens in women admitted to labor and delivery.

STUDY DESIGN

Historical cohort study of all women admitted to labor and delivery at our county hospital over a 5-year period (2010-2014). All patients underwent historical and clinical risk assessment and women perceived to be at increased risk of illicit drug use and who consented to testing had urine toxicology performed. We conducted a detailed chart review on all women with a positive test during this 5-year period and compared them to all women with a negative test in 2014, reporting values significant at a p-value of ≤0.05.

RESULTS

Amongst the 19,604 admissions during this period, 850 women underwent urine toxicology testing, accounting for 4.8% of all admissions. We compared the 83 women who tested positive for illicit drugs (9.8% of all women tested) to the 179 women who tested negative in 2014. Historical drug use was the factor most strongly associated with a positive test. Other historical and demographic factors associated with a positive test included single relationship status, lack of employment, lack of high school education, nulliparity and history of a prior sexually-transmitted or blood-borne infection. Regarding clinical risk factors, maternal medical complications were not associated with a positive test, and obstetrical complications, like preterm labor, were associated with a negative test.

CONCLUSIONS

A positive urine toxicology test was most strongly associated with maternal historical factors, especially known drug use. No clinical risk factor was associated with a positive test. The implications of our findings in guiding targeted laboratory testing are discussed.

Problematisation and regulation: Bodies, risk, and recovery within the context of Neonatal Abstinence Syndrome

BACKGROUND

Neonatal Abstinence Syndrome (NAS) is an anticipated effect of maternal drug use during pregnancy. Yet it remains a contested area of policy and practice. In this paper, we contribute to ongoing debates about the way NAS is understood and responded to, through different treatment regimes, or logics of care. Our analysis examines the role of risk and recovery discourses, and the way in which the bodies of women and babies are conceptualised within these.

METHODS

Qualitative interviews with 16 parents (9 mothers, 7 fathers) and four focus groups with 27 health and social care professionals based in Scotland. All the mothers were prescribed opioid replacement therapy and parents were interviewed after their baby was born. Data collection explored understandings about the causes and consequences of NAS and experiences of preparing for, and caring for, a baby with NAS. Data were analysed using a narrative and discursive approach.

RESULTS

Parent and professional accounts simultaneously upheld and subverted logics of care which govern maternal drug use and the assessment and care of mother and baby. Despite acknowledging the unpredictability of NAS symptoms and the inability of the women who are opioid-dependent to prevent NAS, logics of care centred on 'proving' risk and recovery. Strategies appealed to the need for caution, intervening and control, and obscured alternative logics of care that focus on improving support for mother-infant dyads and the family as a whole.

CONCLUSION

Differing notions of risk and recovery that govern maternal drug use, child welfare and family life both compel and trouble all logics of care. The contentious nature of NAS reflects wider socio-political and moral agendas that ultimately have little to do with meeting the needs of mothers and babies. Fundamental changes in the principles, quality and delivery of care could improve outcomes for families affected by NAS.

Rural and Appalachian Disparities in Neonatal Abstinence Syndrome Incidence and Access to Opioid Abuse Treatment

OBJECTIVE

Incidence of neonatal abstinence syndrome (NAS) is increasing due to the rise in opioid use. Rural states like Kentucky have been disproportionally impacted by opioid abuse, and this study determines NAS burden nationally and in Kentucky while quantifying differences in access to care between Appalachian and non-Appalachian counties.

METHODS

NAS rates were calculated using National (2013) and Kentucky (2008-2014) National Inpatient Sample discharge data. Births were identified using International Classification of Diseases v9 code 779.5 and live birth codes V30.x-V38.x. Counties were classified as rural, micropolitan, or metropolitan using census data. Proximity analysis was conducted via mapping from ZIP code centroid to nearest opioid treatment facility. Distance to treatment facilities was calculated and then compared using nonparametric testing for counties by rural and Appalachian status.

RESULTS

NAS cases tripled from 2008 to 2014 in Kentucky counties, with a 2013 NAS rate more than double the national NAS rate. Rural and Appalachian counties experienced an NAS increase per 1,000 births that was 2-2.5 times higher than urban/non-Appalachian counties, with a greater number of NAS births overall in Appalachian counties. All opioid treatment facility types were further from rural patients than micropolitan/metropolitan patients (P < .001), as well as further for Appalachians versus non-Appalachians (P < .001, all facility types).

CONCLUSIONS

NAS burden disparately affects rural and Appalachian Kentucky counties, while treatment options are disproportionately further away for these residents. Policy efforts to increase NAS prevention and encourage opioid abuse treatment uptake in pregnant women should address rural and Appalachian disparities.