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Morales P, Santiago L, Rosario J, Garcia-Fragoso L, Duconge J, Perez N, Santiago D. Neonatal Abstinence Syndrome and Corresponding Pharmacotherapy Approaches from 2 University-affiliated Neonatal Intensive Care Units in Puerto Rico (2018-2020). PUERTO RICO HEALTH SCIENCES JOURNAL 2024; 43:25-31. [PMID: 38512758 PMCID: PMC11061712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
OBJECTIVE Neonatal abstinence syndrome (NAS) is a set of drug withdrawal symptoms suffered by neonates exposed to drugs in utero. Several studies have widely described NAS incidence and treatment approach; however, little is known regarding the incidence and manifestations of this disease in Puerto Rico (PR). The principal aim of this study was to describe NAS incidence in the neonatal units of hospitals affiliated with the University of PR in terms of occurrence, clinical manifestations, and treatment approaches. METHODS Our study evaluated the medical records of NAS babies diagnosed from 2018 through 2020 at 2 hospitals affiliated with the University of PR Medical Sciences Campus. Descriptive and inferential statistics were employed to analyze trends. RESULTS We identified 12 neonates diagnosed with NAS, 5 with low birthweights (<2500 g); for a NAS incidence of 2 cases per 1000 admitted for the 3 years of recollected data. The urine toxicology results revealed that 9 had experienced intrauterine polydrug exposure. Phenobarbital loading dose were determined on the day of diagnosis (indicated by Finnegan score). The first manifestation of NAS symptoms varied: 8 neonates showed symptoms within 48 hours after birth, whereas 4 had withdrawal symptoms within 72-120 hours of their births. Differences between dosing practices and guidelines were observed, ranging from a 0.69% to a 25% difference during treatment initiation. CONCLUSION Further research on the incidence of NAS in PR (national level) is needed for a deeper understanding that we hope will lead to the development of enhanced treatment protocols in PR.
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Affiliation(s)
- Pamela Morales
- School of Pharmacy, University of Puerto Rico, Medical Sciences Campus
| | | | | | - Lourdes Garcia-Fragoso
- Neonatology section, Department of Pediatrics, School of Medicine, University of Puerto Rico
| | - Jorge Duconge
- School of Pharmacy, University of Puerto Rico, Medical Sciences Campus
| | - Naidy Perez
- The Alliance for Clinical and Translational Research
| | - Darlene Santiago
- School of Pharmacy, University of Puerto Rico, Medical Sciences Campus
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Durrance CP, Atkins DN. Estimating the incidence of substance exposed newborns with child welfare system involvement. CHILD ABUSE & NEGLECT 2024; 149:106629. [PMID: 38232502 DOI: 10.1016/j.chiabu.2023.106629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 12/04/2023] [Accepted: 12/31/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Prenatal substance use can have negative health consequences for both mother and child and may also increase the likelihood of child welfare involvement. The rate of newborns with substance exposure has increased dramatically. As of 2016, federal law requires notification of all infants to child welfare agencies so that a plan of safe care can be developed and referrals to services can be offered. OBJECTIVE Child welfare agencies have not historically collected consistent, systematic data identifying substance exposed newborns. We utilized a unique strategy to identify substance exposed newborns with child welfare involvement. PARTICIPANTS & SETTING We used data from the National Child Abuse & Detection System (NCANDS) which captures N = 3,189,034 unique child protective services investigations for children under the age of 1 between 2004 and 2017. METHODS We calculated the incidence of substance exposed newborns investigated by child welfare agencies and compared with other administrative data on prenatal substance exposure. We also analyzed this rate by infant demographic characteristics (race/ethnicity, sex, rurality). RESULTS Between 2004 and 2017, approximately 13 % of infants reported to child protective services were likely reported because of substance exposure at birth, and the rate of substance exposed newborns with child welfare involvement increased from 3.79 to 12.90 per 1000 births, an increase of 240 %, over this period. CONCLUSIONS Understanding the extent of the substance use crisis for child welfare involvement is important for policymakers to support children and families.
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Affiliation(s)
- Christine Piette Durrance
- La Follette School of Public Affairs, Institute for Research on Poverty, University of Wisconsin, Madison, United States of America.
| | - Danielle N Atkins
- Askew School of Public Administration, Florida State University, United States of America.
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3
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Justvig SP, Su J, Clark LM, Messina C, Sridhar S, Mintzer JP. Regional tissue oxygenation in asymptomatic neonates at high risk for neonatal abstinence syndrome and impact of non-pharmacologic interventions: A case report. J Neonatal Perinatal Med 2024; 17:137-145. [PMID: 38160367 DOI: 10.3233/npm-230099] [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] [Indexed: 01/03/2024]
Abstract
BACKGROUND Improving neonatal abstinence syndrome (NAS) management is an important concern, and objective measures of its physiologic impact remain elusive. We sought to determine whether near-infrared spectroscopy (NIRS)-derived tissue oxygenation (rSO2) and fractional tissue oxygen extraction (FTOE) demonstrated physiologically plausible changes correlating with standard NAS scoring. METHODS Thirty subjects (mean 39 weeks' GA and 3 127 g BW) underwent cerebral and peripheral muscle NIRS monitoring on Days of Life (DOL) Three, Five, and Seven. We examined correlations between NAS scores and FTOE and assessed the impact of non-pharmacologic swaddling and cuddling. RESULTS No statistically significant correlations between NAS scores and FTOE were observed; however, plausible trends were demonstrated between NAS scores and cerebral measurements. Buprenorphine-exposed babies (57%) showed significantly lower FTOE when swaddled (DOL7). CONCLUSIONS Tissue oxygenation monitoring demonstrates potential to provide objective, clinically relevant physiologic information on infants at risk for NAS. Further study is required to determine whether NIRS-derived measures could assist in individualizing NAS care.
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Affiliation(s)
- S P Justvig
- Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - J Su
- General Surgery, University of Hawaii, Honolulu, HI, USA
| | - L M Clark
- Pediatrics, Stony Brook Children's, Stony Brook, NY, USA
| | - C Messina
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - S Sridhar
- Pediatrics, Stony Brook Children's, Stony Brook, NY, USA
| | - J P Mintzer
- Neonatology, Mountainside Medical Center, Montclair, NJ, USA
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Ober C, Bloom L, Obiri N. Implementation of the Eat, Sleep, and Console Model of Care: A Quality Improvement Project. Neonatal Netw 2023; 42:320-328. [PMID: 38000800 DOI: 10.1891/nn-2023-0037] [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] [Accepted: 07/22/2023] [Indexed: 11/26/2023]
Abstract
A Southeastern, 741-bed acute care, Magnet designated teaching hospital and level III B NICU identified assessment and treatment concerns for Neonatal Opioid Withdrawal Syndrome (NOWS). In March 2020, a quality improvement project led to a multidisciplinary team formation to determine the effectiveness of the Eat, Sleep, Console (ESC) model of care in reducing the length of treatment (LOT) and length of stay (LOS) for neonates experiencing NOWS rather than use of the Finnegan Neonatal Abstinence Syndrome Scoring tool. The results concluded a decrease in the average LOT from 19.2 to 2.5 days and the average LOS from 23.9 to 9.3 days for those admitted directly into the ESC model of care on postpartum vs previous direct admission to the NICU. A group samples t-test showed there was a statistically significant decrease in LOS for ESC patients (p < .001) and LOT for ESC patients (p <001).
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Humphries A, Simcox K, Howell B. A review of the literature: How does prenatal opioid exposure impact placental health and fetal brain development? Dev Psychobiol 2023; 65:e22378. [PMID: 36946682 DOI: 10.1002/dev.22378] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/07/2022] [Accepted: 01/05/2023] [Indexed: 03/06/2023]
Abstract
In recent years, there has been a sixfold increase in the number of pregnant people with opioid use disorder (OUD). Rates of neonatal opioid withdrawal syndrome (NOWS), previously known as neonatal abstinence syndrome (NAS), have significantly increased in virtually every state and demographic group (Healthcare Cost Utilization Project, HCUP, 2010). NOWS is a condition resulting from chronic exposure to either therapeutic opioid use (e.g., medication for OUD, chronic pain conditions) or nonprescribed opioid use. To date, there is no known prenatal treatment to help decrease the risk of infants developing NOWS and subsequent neurodevelopmental outcomes. Given the increasing support for how placental signaling, or placental programming, may play a role in downstream pathology, prospective research investigating how the placenta is affected by chronic opioid exposure morphologically, histologically, and at the cellular level may open up potential treatment opportunities in this field. In this review, we discuss literature exploring the physiological roles of nitric oxide and dopamine not only in the vascular development of the placenta, but also in fetal cerebral blood flow, neurogenesis, neuronal differentiation, and neuronal activity. We also discuss histological preclinical studies that suggest chronic opioid exposure to induce some combination of placental dysfunction and hypoxia in a manner similar to other well-known placental pathologies, as denoted by the compensatory neovascularization and increased utilization of the placenta's supply of trophoblast cells, which play an essential role in placental angiogenesis. Overall, we found that the current literature, while limited, suggests chronic opioid exposure negatively impacts placental function and fetal brain development on a cellular and histopathological level. We conclude that it is worthwhile to consider the placenta as a therapeutic target with the ultimate goal of decreasing the incidence of NOWS and the long-term impacts of prenatal opioid exposure.
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Affiliation(s)
- Audrey Humphries
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
- Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, Virginia, USA
| | - Kim Simcox
- Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
- Department of Obstetrics and Gynecology, Carilion Clinic, Roanoke, Virginia, USA
| | - Brittany Howell
- Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, Virginia, USA
- Department of Human Development and Family Science, Virginia Tech, Roanoke, Virginia, USA
- Pediatrics, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
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Marcellus L, Badry D. Infants, children, and youth in foster care with prenatal substance exposure: a synthesis of two scoping reviews. INTERNATIONAL JOURNAL OF DEVELOPMENTAL DISABILITIES 2023; 69:265-290. [PMID: 37025340 PMCID: PMC10071944 DOI: 10.1080/20473869.2021.1945890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background: Infants, children, and youth in foster care have frequently experienced prenatal substance exposure (PSE), neglect, and maltreatment as well as disruptions in their relationships with families. They also have great capacity for overcoming early adversities. In this synthesis of two previously conducted scoping reviews, we aimed to identify and describe literature that identifies a range of interventions that support the health and development of this population. Methods: This review integrates and extends two previously conducted scoping reviews, one focusing on infants and one focusing on children and youth, to synthesize themes across these developmental stages. The Joanna Briggs Institute scoping review methodology was employed for the current and previous reviews. A three-step search strategy identified published studies in the English language from January 2006 to February 2020. Results: One-hundred and fifty-three sources were included in this review. Four themes were identified: (1) early screening, diagnosis, and intervention; (2) providing theoretically grounded care; (3) supporting parents and foster care providers; and (4) intersectoral collaboration. Conclusion:Infants, children, and youth with PSE are overrepresented in foster care. Child welfare system planning should take a multi-sectoral approach to addressing the cumulative needs of this population and their care providers over developmental ages and stages. Although research remains limited, early screening, diagnosis, and developmentally and fetal alcohol spectrum disorder-informed intersectoral interventions are critical for optimizing outcomes.
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Affiliation(s)
| | - Dorothy Badry
- Faculty of Social Work, University of Calgary, Calgary, AB, Canada
- Correspondence to: Dorothy Badry, Faculty of Social Work, University of Calgary, Calgary, AB, Canada.
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Diop H, Cui X, Nielsen T, Peacock-Chambers E, Gupta M. Length of Stay Among Infants with Neonatal Abstinence Syndrome and Risk of Hospital Readmission. Matern Child Health J 2022; 26:2020-2029. [PMID: 35907127 DOI: 10.1007/s10995-022-03481-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess whether a shorter length of stay (LOS) is associated with a higher risk of readmission among newborns with neonatal abstinence syndrome (NAS) and examine the risk, causes, and characteristics associated with readmissions among newborns with NAS, using a longitudinally linked population-based database. METHODS Our study sample included full-term singletons with NAS (n = 4,547) and without NAS (n = 327,836), born in Massachusetts during 2011-2017. We used log-binomial regression models to estimate the crude risk ratios (cRRs) and adjusted RRs with 95% confidence intervals (CI) of the association between LOS and readmissions, controlling for maternal age, race/ethnicity, education, marital status, insurance, method of delivery, birthweight, adequacy of prenatal care, smoking, and abnormal conditions of newborn. RESULTS Compared with infants without NAS, infants with NAS had a non-significantly higher risk of readmission within 2-42 days (2.8% vs. 2.5%; p = 0.17) and a significantly higher risk of readmission within 43-182 days (2.7% vs. 1.8%; p < 0.001). The risk of readmission within 2-42 days was significantly higher among infants with NAS with a LOS of 0-6 days compared to a LOS of 14-20 days (reference group) (aRR: 2.1; 95% CI: 1.2-3.5). No significant differences in readmission rates between 43 and 182 days were observed across LOS categories. CONCLUSIONS Among infants with NAS, a LOS of 0-6 days was associated with a significantly higher risk of readmission within 2-42 days of discharge compared to a longer LOS.
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Affiliation(s)
- Hafsatou Diop
- Massachusetts Department of Public Health, 250 Washington Street, 6th Floor, Boston, MA, 02108, USA.
| | - Xiaohui Cui
- Massachusetts Department of Public Health, 250 Washington Street, 6th Floor, Boston, MA, 02108, USA
| | - Timothy Nielsen
- Massachusetts Department of Public Health, 250 Washington Street, 6th Floor, Boston, MA, 02108, USA
| | | | - Munish Gupta
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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Rutherford K, Maxwell J, Fry L, Holland P, Rigon A, Lankford A. Perceived Clinical Characteristics of Children With History of Opioid Exposure: A Speech-Language Pathology Perspective. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 31:1801-1816. [PMID: 35767339 DOI: 10.1044/2022_ajslp-21-00336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE This research was conducted to describe the clinical characteristics of children with a history of opioid exposure as perceived by the speech-language pathologists (SLPs) treating them. METHOD Three focus groups were conducted. Participants consisted of 20 SLPs working in the schools in West Virginia who had experienced working with children with a confirmed or suspected history of opioid exposure. A thematic, qualitative analysis was conducted, whereby focus group sessions were transcribed verbatim and information was coded, organized into themes, and interpreted. RESULTS Themes of perceived clinical characteristics (speech, language, executive function, and other developmental delays) are reported to address the research question. Additionally, themes derived from the data regarding perceived significant differentiators (greater severity/needs, inconsistent performance, and atypical manifestation) and perceived confounding characteristics (safety and well-being, aspects of home environment, and effects on school environment) that are often reported in children with a history or suspected history of opioid exposure are presented. CONCLUSIONS Perceived clinical characteristics of this population, both intrinsic and situational, highlight the complex profile of this population and demonstrate the importance of considering each child from a multidimensional perspective. Additional research is needed to represent the profile of these children more completely and to identify successful supports that will improve their speech and language outcomes, educational achievement, and their overall quality of life.
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Affiliation(s)
| | | | - Lisa Fry
- Marshall University, Huntington, WV
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Zyoud SH, Al-Jabi SW, Shahwan MJ, Jairoun AA. Global research production in neonatal abstinence syndrome: A bibliometric analysis. World J Clin Pediatr 2022; 11:307-320. [PMID: 35663005 PMCID: PMC9134155 DOI: 10.5409/wjcp.v11.i3.307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/21/2021] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recently, neonatal abstinence syndrome (NAS) emerged as a significant global concern with a dramatic increase in healthcare expenditures. The incidence of the NAS has increased notably in the past decade and emergence as a global public health problem.
AIM To evaluate the development and trend of global NAS research from 1958 to 2019 by bibliometric analysis.
METHODS Analyzed aspects included publication output per year, language, document types, journals, countries/territories, h-index, authors, and top research priorities. The VOSviewer was used to determine the top research priorities, and trends, and to present bibliometric networks concerning various dimensions, such as co-authorship, authors, and countries.
RESULTS A total of 1738 articles were retrieved in the Scopus database from 1958 to 2019. It was found that the great majority of the total NAS documents (n = 1295) were original articles followed by reviews (n = 268) and letters (n = 48). The most productive countries in the NAS field were the United States (n = 833), Canada (n = 112), the United Kingdom (n = 111), and Germany (n = 77). Treatment and hospital outcomes in NAS, evidence-based nurse-driven interventions for the care of newborns with NAS, and a systematic reviews and network meta-analysis for therapeutic approaches of NAS were found in recent years (after 2010), compared with terms such as pathophysiology, mechanisms of NAS, and signs and symptoms in the early years.
CONCLUSION Treatment and pediatric outcomes and the effectiveness of pharmacological treatment may be frontiers in the NAS field, and continued efforts from researchers are needed in those topics.
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Affiliation(s)
- Sa'ed H Zyoud
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus 44839, Palestine
- Poison Control and Drug Information Center, College of Medicine and Health Sciences, An-Najah National University, Nablus 44839, Palestine
- Clinical Research Centre, An-Najah National University Hospital, Nablus 44839, Palestine
| | - Samah W Al-Jabi
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus 44839, Palestine
| | - Moyad Jamal Shahwan
- Clinical Sciences, Ajman University, Ajman 2758, United Arab Emirates
- Centre of Medical and Bio‑allied Health Sciences Research, Ajman University, Ajman 2758, United Arab Emirates
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10
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Zyoud SH, Al-Jabi SW, Shahwan MJ, Jairoun AA. Global research production in neonatal abstinence syndrome: A bibliometric analysis. World J Clin Pediatr 2022; 11:308-321. [DOI: 10.5409/wjcp.v11.i3.308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recently, neonatal abstinence syndrome (NAS) emerged as a significant global concern with a dramatic increase in healthcare expenditures. The incidence of the NAS has increased notably in the past decade and emergence as a global public health problem.
AIM To evaluate the development and trend of global NAS research from 1958 to 2019 by bibliometric analysis.
METHODS Analyzed aspects included publication output per year, language, document types, journals, countries/territories, h-index, authors, and top research priorities. The VOSviewer was used to determine the top research priorities, and trends, and to present bibliometric networks concerning various dimensions, such as co-authorship, authors, and countries.
RESULTS A total of 1738 articles were retrieved in the Scopus database from 1958 to 2019. It was found that the great majority of the total NAS documents (n = 1295) were original articles followed by reviews (n = 268) and letters (n = 48). The most productive countries in the NAS field were the United States (n = 833), Canada (n = 112), the United Kingdom (n = 111), and Germany (n = 77). Treatment and hospital outcomes in NAS, evidence-based nurse-driven interventions for the care of newborns with NAS, and a systematic reviews and network meta-analysis for therapeutic approaches of NAS were found in recent years (after 2010), compared with terms such as pathophysiology, mechanisms of NAS, and signs and symptoms in the early years.
CONCLUSION Treatment and pediatric outcomes and the effectiveness of pharmacological treatment may be frontiers in the NAS field, and continued efforts from researchers are needed in those topics.
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Affiliation(s)
- Sa'ed H Zyoud
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus 44839, Palestine,Poison Control and Drug Information Center, College of Medicine and Health Sciences, An-Najah National University, Nablus 44839, Palestine,Clinical Research Centre, An-Najah National University Hospital, Nablus 44839, Palestine
| | - Samah W Al-Jabi
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus 44839, Palestine
| | - Moyad Jamal Shahwan
- Clinical Sciences, Ajman University, Ajman 2758, United Arab Emirates,Centre of Medical and Bio‑allied Health Sciences Research, Ajman University, Ajman 2758, United Arab Emirates
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Morris E, Bardsley T, Schulte K, Seidel J, Shakib JH, Buchi KF, Fung CM. Hospital Outcomes of Infants with Neonatal Opioid Withdrawal Syndrome at a Tertiary Care Hospital with High Rates of Concurrent Nonopioid (Polysubstance) Exposure. Am J Perinatol 2022; 39:387-393. [PMID: 32892326 PMCID: PMC8632549 DOI: 10.1055/s-0040-1716490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Neonatal opioid withdrawal syndrome (NOWS) describes infants' withdrawal signs and symptoms after birth due to an interruption of prenatal opioid exposure. Many infants with NOWS are also exposed to nonopioids, however. This study was to determine hospital outcomes of infants exposed to opioids alone or coexposed with nonopioid substances (polysubstance). STUDY DESIGN We reviewed infants of ≥34 weeks of gestation with prenatal opioid exposure from April 2015 to May 2018. We compared the median lengths of stay (LOS) and treatment (LOT) and the percentages of infants requiring pharmacologic and adjunctive treatment in infants exposed to opioids alone or polysubstance. We used Wilcoxon's test for continuous outcomes or Chi-squared test for categorical outcomes to determine statistical significance. We used multivariable regression model to calculate each drug category's estimates of adjusted mean ratios for LOS and LOT plus estimates of adjusted odds ratios for pharmacologic/adjunctive treatments. RESULTS Of the 175 infants, 33 (19%) infants had opioid exposure alone. Opioid exposure included short- and/or long-acting opioids. A total of 142 (81%) had polysubstance exposure with 47% of mothers using nicotine products. We saw similar hospital outcomes between infants exposed to opioids alone or polysubstance; however, a higher percentage of infants with both short- and long-acting opioid exposure required pharmacologic treatment compared with either opioid alone. Focusing on individual drug categories, we detected differential hospital outcomes in which short-acting opioids decreased LOT, whereas long-acting opioids increased LOS, LOT, and need for pharmacologic and adjunctive treatment. Coexposure of opioids with stimulants decreased LOT and reduced need for adjunctive treatment. Coexposures with antidepressants increased LOT, while with antiepilepetics increased LOS. CONCLUSION Because infants with NOWS often have coexposures to other nonopioid substances, appreciating the associated risks of individual or combination of drugs in modulating hospital outcomes may help counsel families on their infants' expected hospital course. KEY POINTS · Hospital outcomes were similar between infants exposed to opioids alone or polysubstance including opioids.. · Infants with short- and long-acting opioids required pharmacologic treatment more often than either opioid alone.. · Differential hospital outcomes exist for various co-exposures of opioids with nonopioids..
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Affiliation(s)
- Erin Morris
- Department of Pediatrics, Residency & Fellowship Program, Salt Lake City, Utah
| | - Tyler Bardsley
- Division of Epidemiology, University of Utah Study Design and Biostatistics Center, University of Utah School of Medicine, Salt Lake City, Utah
| | - Krista Schulte
- College of Nursing, University of Utah, Salt Lake City, Utah
| | - Jeanette Seidel
- College of Nursing, University of Utah, Salt Lake City, Utah
| | - Julie H. Shakib
- Division of General Pediatrics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Karen F. Buchi
- Division of General Pediatrics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Camille M. Fung
- Division of Pediatric Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
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Designing and Implementing a Skin Care Protocol for Infants With Neonatal Abstinence Syndrome to Decrease Rates of Diaper Dermatitis. Adv Neonatal Care 2022; 22:35-41. [PMID: 34054014 DOI: 10.1097/anc.0000000000000898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infants with neonatal abstinence syndrome (NAS) are at an increased risk for diaper dermatitis, which can cause skin breakdown and lead to significant pain and potential infection exposure. Skin care protocols in the neonatal intensive care unit (NICU) setting seldom specifically address the needs of this at-risk population, leading to inconsistent skin care management. PURPOSE The goal was to support a decrease in the rate of diaper dermatitis for infants with NAS by designing and implementing an evidence-based skin care protocol. METHODS A retrospective medical record review was used to examine outcomes of 25 infants preintervention and 8 infants postintervention. The skin care protocol was a bundle of 5 evidence-based interventions: (1) a specific diaper dermatitis assessment tool; (2) frequent diaper changes with superabsorbent diapers; (3) application of petroleum jelly and alcohol-free wipes; (4) infant bathing in pH neutral soap; and (5) application of zinc oxide barrier cream for erythema. RESULTS There was an overall 80.5% decrease in diaper dermatitis from pre- to postimplementation (P ≤ .01) as noted when comparing positive cases of diaper dermatitis with negative cases from pre- to postintervention. IMPLICATIONS FOR PRACTICE Expanding the skin care protocol to all neonates in the NICU and nursery could aid in maintaining skin integrity and decreasing diaper dermatitis in the NICU. More research is needed following this study for the data to be generalizable to other NICUs. This study offers key takeaways including using a specific diaper dermatitis assessment tool and consistently using the bundle of interventions. VIDEO ABSTRACT AVAILABLE AT https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=47.
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Zipursky J, Juurlink DN. Opioid use in pregnancy: An emerging health crisis. Obstet Med 2021; 14:211-219. [PMID: 34880933 PMCID: PMC8646213 DOI: 10.1177/1753495x20971163] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/07/2020] [Indexed: 04/17/2024] Open
Abstract
Opioid use in pregnancy has increased in parallel to the opioid crisis observed in the general population. Rising rates of peripartum opioid use pose a significant public health concern for both mothers and their children. Pregnancy also represents a unique opportunity for healthcare providers to screen women for opioid use disorder and engage them in appropriate care. In the present review, we describe patterns of opioid use in pregnancy and how this relates to maternal and neonatal health outcomes. We also examine screening for and treatment of opioid use disorder in pregnancy, neonatal outcomes following maternal opioid use, and breastfeeding recommendations for women taking opioids postpartum.
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Affiliation(s)
- Jonathan Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - David N Juurlink
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
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Cain SM, Conway A, Combs-Orme T, Bruck SL, Cook EK, Thomas E. Neonatal Abstinence Syndrome in Rural Appalachia. SOCIAL WORK 2021; 66:197-205. [PMID: 34143884 DOI: 10.1093/sw/swab014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 06/12/2023]
Abstract
As the United States faces the repercussions of the current opioid epidemic, it is important for social workers to be able to identify risks for poor birth outcomes in infants with neonatal abstinence syndrome (NAS). Although some studies have identified single risk factors, no studies have tested associations between total amount of risk (that is, cumulative risk) and birth outcomes in infants with NAS. Authors examined 318 mothers who used opioids during pregnancy and their infants' birthweight, length, head circumference, and Apgar scores (which measure overall infant health after birth). All infants were admitted to a neonatal intensive care unit in Appalachia and were diagnosed with NAS. Authors found that high cumulative risk during pregnancy was associated with lower birthweight and Apgar scores one and five minutes after birth as well as shorter length and smaller head circumference at birth. Social workers are encouraged to assess for the quantity of prenatal adversity experienced by the mothers they serve and to consider multicomponent, comprehensive community-based interventions to reduce cumulative risk.
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Affiliation(s)
- Shannon M Cain
- doctoral student and graduate research assistant, College of Social Work, University of Tennessee, Knoxville
| | - Anne Conway
- associate professor, College of Social Work, University of Tennessee, Knoxville
| | - Terri Combs-Orme
- professor emeritus, College of Social Work, University of Tennessee, Knoxville
| | - Sarah L Bruck
- outpatient therapist, Camelot Care Centers, Knoxville, TN
| | - E Kyle Cook
- neonatal nurse practitioner, Pediatrix Medical Group, East Tennessee Children's Hospital, Knoxville
| | - Elizabeth Thomas
- assistant professor, College of Social Work, University of Tennessee, Knoxville
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Eudy-Byrne R, Zane N, Adeniyi-Jones SC, Gastonguay MR, Ruiz-Garcia A, Kushal G, Kraft WK. Pharmacometric dose optimization of buprenorphine in neonatal opioid withdrawal syndrome. Clin Transl Sci 2021; 14:2171-2183. [PMID: 34080312 PMCID: PMC8604235 DOI: 10.1111/cts.13074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/19/2021] [Accepted: 05/02/2021] [Indexed: 11/30/2022] Open
Abstract
Results from Blinded Buprenorphine OR Neonatal morphine solution (BBORN), a previous phase III trial in infants with neonatal opioid withdrawal syndrome (NOWS), demonstrated that sublingual buprenorphine resulted in a shorter duration of treatment and shorter length of hospital stay than the comparator, oral morphine. Objectives of Buprenorphine Pharmacometric Open Label Research study of Drug Exposure (BPHORE), a new trial with buprenorphine in a similar population, were to (1) optimize initial dose, up-titration to achieve symptom control and weaning steps of pharmacologic treatment and (2) investigate safety of the revised regimen. A pharmacodynamic model linked buprenorphine exposure to NOWS symptom scores. Adaptive dose regimens were simulated using BBORN results to compare dosing regimens for times to stabilization, weaning, and cessation. A clinical trial using model informed doses (BPHORE), was conducted. Simulations indicated benefits in time to stabilization and weaning when up-titration rates increased to 30%. Stabilization time was not greatly impacted by the starting dose. Time to wean and time to cessation were dose dependent. A weaning rate of 25% shortened time to cessation. Ten infants were enrolled in BPHORE using buprenorphine starting dose of 24 µg/kg/day, 33% titration, and 15% wean rate. Five subjects required adjuvant therapy. Half-maximal effective concentration (EC50 ) values indicated maximum buprenorphine doses did not generate maximal effect size, suggesting potential efficacy of a further increased dose if a goal was to reduce the use of adjunct agents. Simulations indicated that further benefits can be gained by increasing starting doses of buprenorphine and increasing wean rates. Use of a model-based analysis to provide focused guidelines for care can be used with goals of reducing treatment time and hospital stays in infants with NOWS.
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Affiliation(s)
| | - Nicole Zane
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan C Adeniyi-Jones
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Nemours DuPont at Jefferson, Philadelphia, Pennsylvania, USA
| | | | | | - Gagan Kushal
- Department of Pharmacy, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Walter K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Eaves ER, Barber J, Whealy R, Clancey SA, Wright R, Cocking JH, Spadafino J, Hepp CM. Characterization of neonatal opioid withdrawal syndrome in Arizona from 2010-2017. PLoS One 2021; 16:e0248476. [PMID: 34081702 PMCID: PMC8174702 DOI: 10.1371/journal.pone.0248476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 02/28/2021] [Indexed: 11/21/2022] Open
Abstract
In this paper, we describe a population of mothers who are opioid dependent at the time of giving birth and neonates exposed to opioids in utero who experience withdrawal following birth. While there have been studies of national trends in this population, there remains a gap in studies of regional trends. Using data from the Arizona Department of Health Services Hospital Discharge Database, this study aimed to characterize the population of neonates with neonatal opioid withdrawal syndrome (NOWS) and mothers who were opioid dependent at the time of giving birth, in Arizona. We analyzed approximately 1.2 million electronic medical records from the Arizona Department of Health Services Hospital Discharge Database to identify patterns and disparities across socioeconomic, ethnic, racial, and/or geographic groupings. In addition, we identified comorbid conditions that are differentially associated with NOWS in neonates or opioid dependence in mothers. Our analysis was designed to assess whether indicators such as race/ethnicity, insurance payer, marital status, and comorbidities are related to the use of opioids while pregnant. Our findings suggest that women and neonates who are non-Hispanic White and economically disadvantaged, tend be part of our populations of interest more frequently than expected. Additionally, women who are opioid dependent at the time of giving birth are unmarried more often than expected, and we suggest that marital status could be a proxy for support. Finally, we identified comorbidities associated with neonates who have NOWS and mothers who are opioid dependent not previously reported.
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Affiliation(s)
- Emery R. Eaves
- Department of Anthropology, Northern Arizona University, Flagstaff, Arizona, United States of America
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, United States of America
- Southwest Health Equity Research Collaborative, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Jarrett Barber
- Southwest Health Equity Research Collaborative, Northern Arizona University, Flagstaff, Arizona, United States of America
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Ryann Whealy
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, Arizona, United States of America
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Sara A. Clancey
- Institute for Human Development, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Rita Wright
- Department of Social Work, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Jill Hager Cocking
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, Arizona, United States of America
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Joseph Spadafino
- Arizona Department of Health Services, Phoenix, Arizona, United States of America
| | - Crystal M. Hepp
- Southwest Health Equity Research Collaborative, Northern Arizona University, Flagstaff, Arizona, United States of America
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, Arizona, United States of America
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
- * E-mail:
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Shifting the care paradigm for opioid-exposed newborns in Southern Colorado. J Perinatol 2021; 41:1372-1380. [PMID: 33288868 DOI: 10.1038/s41372-020-00900-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Compare Eat, Sleep, Console (ESC) and limited opioid treatment on birth length of stay (LOS), postnatal opioid exposure, and 30-day re-hospitalizations in opioid-exposed newborns (OENs) in two hospital systems. STUDY DESIGN Quality improvement teams supported change from scheduled methadone using Finnegan scores to standardized non-pharmacologic support using ESC. Intermittent morphine was used only if needed. Statistical process control charts examined changes over time. RESULT Between 2017 and 2019 we treated 280 OENs ≥35 weeks' gestation, 101 and 179 per hospital. Post-ESC, LOS decreased 51.2% (16.8-8.2 days), postnatal opioid treatment decreased from 64.1 to 29.9%; percent decline in both hospitals was similar. 30-day re-hospitalizations were 5/103 (4.8%) pre-ESC, and 7/177 (4.0%) post-ESC (p = 0.72, NS). Multiple substance co-exposures were common (226/280, 80.7%). CONCLUSION ESC and as needed morphine decreased LOS and postnatal opioid exposure for OENs in two hospital systems without increasing 30-day readmissions. ESC appears effective in OENs with multiple co-exposures.
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Lanzillotta-Rangeley J, Zeller TA, Beachler T, Litwin AH, Clark A, Stem J. The Impact of the Disease Model of Substance Use Disorder on Evidence Based Practice Adoption and Stigmatizing Attitudes: A Comparative Analysis. Pain Manag Nurs 2021; 22:616-622. [PMID: 33906806 DOI: 10.1016/j.pmn.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 01/17/2021] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Evidence-based practices are shown to improve health outcomes in persons with substance use disorder (SUD), but practice adoption is often limited by stigma. Stigma towards these patients leads to poor communication, missed diagnoses, and treatment avoidance. AIMS The purpose of this study was to survey a rural community to conceptualize knowledge and attitudes towards SUD and opioid use disorder. DESIGN The study design was cross-sectional survey using a convenience sample in a rural community in southwestern Ohio. METHODS A 25-item electronic survey was created to assess knowledge and attitudes of the community towards SUD, evidenced-based practices, and stigma. Questions were grouped into five subcategories to meaningfully address high-priority areas. Descriptive statistics included frequencies and percentages. A comparative analysis was performed using Chi-square and phi to evaluate response rates from the first question, A substance use disorder is a real illness like diabetes and heart disease, to the other survey questions. RESULTS A total of 173 people responded to the survey. The response to "A substance use disorder is a real illness like diabetes and heart disease" resulted in two groups of similar size, with 83 (48.5%) of the respondents agreeing with the statement. There was a significant difference (p < .001) in 15 questions between the two groups. CONCLUSIONS People who believe SUD is a real illness were more likely to support evidence-based treatment practices, show less stigma towards those suffering from SUD, and support harm reduction services.
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Affiliation(s)
| | - Timothy A Zeller
- Seneca Family Medicine Residency Program, Prisma Health, Seneca, South Carolina; University of South Carolina School of Medicine - Greenville, Greenville, South Carolina
| | - Taylor Beachler
- Prisma Health Addiction Research Center, Greenville, South Carolina
| | - Alain H Litwin
- University of South Carolina School of Medicine - Greenville, Greenville, South Carolina; Prisma Health Addiction Research Center, Greenville, South Carolina; Clemson University School of Health Research, Clemson, South Carolina
| | - Angela Clark
- University of Cincinnati, College of Nursing, Cincinnati, Ohio
| | - Jack Stem
- University of Cincinnati, College of Nursing, Cincinnati, Ohio
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Vasan V, Kitase Y, Newville JC, Robinson S, Gerner G, Burton VJ, Jantzie LL. Neonatal opioid exposure: public health crisis and novel neuroinflammatory disease. Neural Regen Res 2021; 16:430-432. [PMID: 32985461 PMCID: PMC7996018 DOI: 10.4103/1673-5374.293136] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 03/31/2020] [Accepted: 04/20/2020] [Indexed: 11/04/2022] Open
Abstract
Substance use, specifically the use of prescription and non-prescription opioids among pregnant women, is a major public health issue and chief contributor to the opioid crisis. The prevalence of Neonatal Opioid Withdrawal Syndrome has risen 5-fold in the past decade, and is a well-recognized consequence of perinatal opioid exposure. By contrast, the long-term damage to the developing brain from opioid medications is just beginning to be recognized as a serious concern. Published data suggest that opioid exposure commencing in utero negatively affects the maturation of the neural-immune system, and trajectory of central nervous system development. Methadone induces peripheral immune hyper-reactivity, lasting structural and microstructural brain injury, and significant deficits in executive function and cognitive control in adult animals following in utero exposure. Thus, to address the cascading public health crisis stemming from the multitude of infants with in utero opioid exposure who will grow up with altered neurodevelopmental trajectories, rigorous preclinical, mechanistic studies are required. Such studies will define the long-term sequelae of prenatal opioid exposure in an effort to develop appropriate and targeted interventions. Specifically, the development of novel fluid, neuroimaging and biobehavioral biomarkers will be the most useful to aid in early identification and treatment of opioid exposed infants with the greatest risk of poor clinical outcomes. These studies will be essential to understand how in utero insults determine brain structure and function in adulthood, and what targeted interventions will be required to improve long-term outcomes in the countless children being born exposed to opioids each year.
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Affiliation(s)
- Vikram Vasan
- Department of Pediatrics, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Kennedy Krieger Institute, Baltimore, MD; Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM; Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Yuma Kitase
- Department of Pediatrics, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Kennedy Krieger Institute, Baltimore, MD; Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM; Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Jessie C. Newville
- Department of Pediatrics, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Kennedy Krieger Institute, Baltimore, MD; Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM; Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Shenandoah Robinson
- Department of Pediatrics, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Kennedy Krieger Institute, Baltimore, MD; Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM; Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Gwendolyn Gerner
- Department of Pediatrics, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Kennedy Krieger Institute, Baltimore, MD; Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM; Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - V. Joanna Burton
- Department of Pediatrics, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Kennedy Krieger Institute, Baltimore, MD; Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM; Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Lauren L. Jantzie
- Department of Pediatrics, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Kennedy Krieger Institute, Baltimore, MD; Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM; Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
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20
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Darlington CK, Compton PA, Hutson SP. Revisiting the Fetal Assault Law in Tennessee: Implications and the Way Forward. Policy Polit Nurs Pract 2021; 22:93-104. [PMID: 33567969 DOI: 10.1177/1527154421989994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The rising prevalence of opioid use disorder (OUD) among those living in the United States has demanded a collaborative response from health care and policy spheres. Addressing OUD among pregnant women is especially difficult, given the controversies surrounding the medical and ethical balance between meeting maternal versus fetal/newborn needs. Most medical organizations discourage the criminalization of drug use in pregnancy due to the adverse public health outcomes of such an approach. Despite this recommendation, many states continue to use punitive law to address drug use in pregnancy. In 2014, the Fetal Assault Law in Tennessee (TN) became the first law in the United States to directly allow women to be prosecuted for drug use in pregnancy. Since its expiration in 2016, this law has been re-introduced several times to the TN legislature in support of permanent implementation. This article outlines the impact of the initial Fetal Assault Law on maternal/newborn health in TN and provides alternative immediate, short-term, and long-term health policy strategies through which health care providers and legislators can better advocate for the well-being of both mothers with OUD and their infants.
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21
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Jaekel J, Kim HM, Lee SJ, Schwartz A, Henderson JMT, Woodward LJ. Emotional and Behavioral Trajectories of 2 to 9 Years Old Children Born to Opioid-Dependent Mothers. Res Child Adolesc Psychopathol 2021; 49:443-457. [PMID: 33433780 PMCID: PMC7943531 DOI: 10.1007/s10802-020-00766-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2020] [Indexed: 12/20/2022]
Abstract
Maternal opioid use in pregnancy has increased dramatically. Knowledge about children's longer-term emotional and behavioral development after prenatal opioid exposure is scarce. A regional sample of 89 opioid-exposed and 104 non-exposed comparison children were studied prospectively at ages 2, 4.5, and 9 years using the Strengths and Difficulties Questionnaire (SDQ) completed by primary caregivers. Across all childhood assessments, opioid-exposed children obtained significantly higher total difficulties scores than non-exposed comparison children. Growth curve modeling revealed that, relative to their same age peers, opioid-exposed children's emotional and behavioral difficulties significantly worsened over time. Moreover, fixed effects estimates showed that total difficulties trajectories were poorer for children subject to higher prenatal risk (Est = 1.78, 95% CI = [0.46, 3.09]) who were born to mothers with high levels of social adversity (1.11 [0.51, 1.71]), and were then raised in families characterized by high levels of psychosocial risk (1.94 [0.90, 2.98]) and unstable caregiving (1.91 [0.33, 3.48]). A complex set of pre- and postnatal processes contribute to opioid-exposed children's emotional and behavioral development. Efforts to mitigate the long-term consequences of opioid use in pregnancy need to consider both children's and their caregivers' biopsychosocial risks.
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Affiliation(s)
- Julia Jaekel
- Department of Child & Family Studies, University of Tennessee Knoxville, Knoxville, USA. .,Department of Psychology, University of Tennessee Knoxville, Knoxville, USA. .,Department of Psychology, University of Warwick, Coventry, UK.
| | - Hyun M Kim
- School of Health Sciences, University of Canterbury, Christchurch, New Zealand
| | - Samantha J Lee
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
| | - Ashlyn Schwartz
- Department of Public Health, University of Tennessee Knoxville, Knoxville, USA
| | | | - Lianne J Woodward
- School of Health Sciences, University of Canterbury, Christchurch, New Zealand
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Doherty KM, Scott TA, Morad A, Crook T, McNeer E, Lovell KS, Gay JC, Patrick SW. Evaluating Definitions for Neonatal Abstinence Syndrome. Pediatrics 2021; 147:e2020007393. [PMID: 33268396 PMCID: PMC7780959 DOI: 10.1542/peds.2020-007393] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES National estimates indicate that the incidence of neonatal abstinence syndrome (NAS), a postnatal opioid withdrawal syndrome, increased more than fivefold between 2004 and 2016. There is no gold standard definition for capturing NAS across clinical, research, and public health settings. Our objective was to evaluate how different definitions of NAS modify the calculated incidence when applied to a known population of opioid-exposed infants. METHODS Data for this retrospective cohort study were obtained from opioid-exposed infants born at Vanderbilt University Medical Center in 2018. Six commonly used clinical and surveillance definitions of opioid exposure and NAS were applied to the study population and evaluated for accuracy in assessing clinical withdrawal. RESULTS A total of 121 opioid-exposed infants met the criteria for inclusion in our study. The proportion of infants who met criteria for NAS varied by predefined definition, ranging from 17.4% for infants who received morphine to 52.8% for infants with the diagnostic code for opioid exposure. Twenty-eight infants (23.1%) received a clinical diagnosis of NAS by a medical provider, and 38 (34.1%) received the diagnostic code for NAS at discharge. CONCLUSIONS We found significant variability in the incidence of opioid exposure and NAS among a single-center population using 6 common definitions. Our findings suggest a need to develop a gold standard definition to be used across clinical, research, and public health surveillance settings.
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Affiliation(s)
- Kathleen M Doherty
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee;
| | - Theresa A Scott
- Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and
| | - Anna Morad
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Travis Crook
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth McNeer
- Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and
- Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Kim S Lovell
- Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and
| | - James C Gay
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen W Patrick
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and
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Definitions of neonatal abstinence syndrome in clinical studies of mothers and infants: an expert literature review. J Perinatol 2021; 41:1364-1371. [PMID: 33514878 PMCID: PMC8225507 DOI: 10.1038/s41372-020-00893-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/09/2020] [Accepted: 11/20/2020] [Indexed: 01/31/2023]
Abstract
Neonatal abstinence syndrome (NAS) results from discontinuation of in utero exposures to opioids/substances. The rising incidence of NAS has prompted an increased need for accurate research and public health data. To examine how NAS has been defined in clinical studies of opioid-exposed mothers and infants, a review process was developed based on the RAND/UCLA Appropriateness Method, yielding 888 abstracts. Per inclusion criteria, 57 abstracts underwent full-text review. To define NAS, studies cited using modified versions of the Finnegan NAS scoring tool (n = 21; 37%), ICD-9/10 coding (n = 17; 30%), original Finnegan tool (n = 16; 28%), Eat Sleep Console (n = 3; 5%), and Lipsitz (n = 3; 5%) tools, (3 cited 2+ tools). Most studies utilized subjective NAS scoring/assessment algorithms and neonatal coding as key elements defining NAS. While most cited opioid exposure as integral to their inclusion criteria, 26% did not. These approaches highlight the need for a more refined and standardized definition of NAS.
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Wijekoon N, Aduroja O, Biggs JM, El-Metwally D, Gopalakrishnan M. Model-Based Approach to Improve Clinical Outcomes in Neonates With Opioid Withdrawal Syndrome Using Real-World Data. Clin Pharmacol Ther 2020; 109:243-252. [PMID: 33119888 DOI: 10.1002/cpt.2093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/11/2020] [Indexed: 12/13/2022]
Abstract
At least 60% of the neonates with opioid withdrawal syndrome (NOWS) require morphine to control withdrawal symptoms. Currently, the morphine dosing strategies are empiric, not optimal and associated with longer hospital stay. The aim of the study was to develop a quantitative, model-based, real-world data-driven approach to morphine dosing to improve clinical outcomes, such as reducing time on treatment. Longitudinal morphine dose, clinical response (Modified Finnegan Score (MFS)), and baseline risk factors were collected using a retrospective cohort design from the electronic medical records of neonates with NOWS (N = 177) admitted to the University of Maryland Medical Center. A dynamic linear mixed effects model was developed to describe the relationship between MFS and morphine dose adjusting for baseline risk factors using a split-sample data approach (70% training: 30% test). The training model was evaluated in the test dataset using a simulation based approach. Maternal methadone and benzodiazepine use, and race were significant predictors of the MFS response. Positive autocorrelations of 0.56 and 0.12 were estimated between consecutive MFS responses. On an average, for a 1,000 μg increase in the morphine dose, the MFS decreased by 0.3 units. The model evaluation showed that observed and predicted median time on treatment were similar (13.0 vs. 13.8 days). A model-based framework was developed to describe the MFS-morphine dose relationship using real-world data that could potentially be used to develop an adaptive, individualized morphine dosing strategy to improve clinical outcomes in infants with NOWS.
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Affiliation(s)
- Nadeesri Wijekoon
- Department of Mathematics and Statistics, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Oluwatobi Aduroja
- Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Jessica M Biggs
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Dina El-Metwally
- Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
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25
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Abstract
BACKGROUND There has been an increase in infants with neonatal abstinence syndrome (NAS) in neonatal intensive care units (NICUs) over the past several decades. Infants with NAS experience withdrawal as a result of the sudden termination at birth of substance exposure during pregnancy. A serious sign related to infants diagnosed with NAS is poor feeding. The prevalence of NAS urges researchers and clinicians to develop effective strategies and techniques to treat and manage the poor feeding of infants exposed to substances in utero. PURPOSE To synthesize current feeding methods and practices used for infants diagnosed with NAS. METHODS/SEARCH STRATEGY PubMed, CINAHL, and Scopus were searched for articles published within the last 20 years that focused on feeding practices or feeding schedules, were written in English, were peer-reviewed, and described human studies. The search terms utilized were "neonatal abstinence syndrome" OR "neonatal opioid withdrawal syndrome" AND "feeding." FINDINGS/RESULTS Three findings emerged regarding techniques and management of poor feeding in the NAS population. The findings included infants who received mother's own milk had decreased severity and later onset of clinical signs of withdrawal, demand feeding is recommended, and the infant's cues may be helpful to follow when feeding. IMPLICATIONS FOR PRACTICE Clinicians should encourage mother's own milk in this population unless contraindications are present. Caregivers and clinicians must be receptive to cues when feeding infants with NAS. IMPLICATIONS FOR RESEARCH Even with the clinical knowledge and experience that infants with NAS are difficult to feed, there is limited research assessing techniques and schedules that are effective in managing successful feeding. Future research should compare feeding schedules such as on-demand feeding versus regimented feeding schedules, as well as investigate techniques that mothers and nurses can utilize to encourage oral intake in this population.Video abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=37.
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26
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Wouldes TA, Woodward LJ. Neurobehavior of newborn infants exposed prenatally to methadone and identification of a neurobehavioral profile linked to poorer neurodevelopmental outcomes at age 24 months. PLoS One 2020; 15:e0240905. [PMID: 33064777 PMCID: PMC7567379 DOI: 10.1371/journal.pone.0240905] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022] Open
Abstract
The abuse of prescription opioids and heroin by women of childbearing age over the past decade has resulted in a five-fold increase in the number of infants born opioid-dependent. Daily opioid substitution treatment with methadone is associated with less maternal illicit opioid use and improved antenatal care. However, research on the neurobehavioral effects of daily prenatal exposure to methadone on the infant is limited. Using the NICU Network Neurobehavioral Scale (NNNS), we compared the neurobehavior at birth of 86 infants born to opioid-dependent mothers receiving methadone treatment (MMT) with 103 infants unexposed to methadone. Generalized linear models, adjusted for covariates, showed methadone exposed infants had significantly poorer attention, regulation, and quality of movement. They were also significantly more excitable, more easily aroused, exhibited more non-optimal reflexes, hypertonicity, and total signs of stress abstinence. Maternal MMT was also associated with more indices of neonatal abstinence, including: CNS, visual, genitourinary (GI), and state. Latent profile analysis of the NNNS summary scores revealed four distinct neurobehavioral profiles with infants characterized by the most disturbed neurobehavior at birth having the poorest clinical outcomes at birth, and poorer cognitive and motor development at 24 months of age.
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Affiliation(s)
- Trecia A. Wouldes
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Lianne J. Woodward
- School of Health Sciences, University of Canterbury, Christchurch, New Zealand
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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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Tressler SR, Kushner T, Bhandari R. Factors Associated With Hepatitis B Exposure Among People Who Report Using Methamphetamine: National Health and Nutrition Examination Survey 2009-2016. J Infect Dis 2020; 221:243-250. [PMID: 31504660 DOI: 10.1093/infdis/jiz445] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 08/29/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND With the nation's focus on the opioid crisis, methamphetamine has made a comeback, potentially increasing risk for hepatitis B. We examined factors associated with hepatitis B virus (HBV) exposure among people who reported ever using methamphetamine in a nationally representative survey. METHODS We used the National Health and Nutrition Examination Survey to examine factors associated with HBV exposure among participants who reported ever using methamphetamine using bivariate and multivariable logistic regression. RESULTS Overall, 847 participants met the study inclusion criteria. In multivariable logistic regression, female sex (adjusted odds ratio, 3.83; 95% confidence interval, 1.65-8.90), living below the poverty threshold (3.17; 1.39-7.21), injection drug use (4.89; 1.95-12.26), active hepatitis C virus infection (3.39; 1.10-12.26), and identifying as men who have sex with men (28.21; 5.19-153.38) were significantly associated with HBV exposure. CONCLUSIONS The odds of HBV exposure for female participants who reported using methamphetamine were 4 times than that for male participants. Poverty, injection drug use, and hepatitis C virus infection were also associated. As methamphetamine use increases, it is critical to identify those at risk of acquiring HBV infections in order to target testing and vaccination.
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Affiliation(s)
- Stacy R Tressler
- Department of Epidemiology, West Virginia University, Morgantown, West Virginia, USA
| | - Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ruchi Bhandari
- Department of Epidemiology, West Virginia University, Morgantown, West Virginia, USA
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Jackson HJ, Lopez C, Miller S, Englehardt B. Feasibility of auricular acupressure as an adjunct treatment for neonatal opioid withdrawal syndrome (NOWS). Subst Abus 2020; 42:348-357. [PMID: 32635829 DOI: 10.1080/08897077.2020.1784360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The opioid epidemic in the United States continues to threaten public health. As a result of this crisis, neonatal opioid withdrawal syndrome (NOWS) has risen exponentially and requires a multitude of non-pharmacologic treatments to ensure healthy neonatal outcomes. Methods: This feasibility study implemented an acupressure protocol as informed by the Near-Term Infant (NTI) conceptual framework for the treatment of NOWS. Aims of this study were to assess provider training, effective integration of acupressure within the standard of care, and acceptance of this treatment by mothers and healthcare providers. Results: With maternal consent, a total of 12 participants were enrolled and underwent auricular acupressure. Nurse Practitioners were credentialed (75%) and effectively administered neonatal acupressure (100%) in accordance with the study protocol. Mothers were very satisfied with acupressure for the treatment of NOWS (Client Satisfaction Questionaire-8 mean scores 3.8-4.0 of a possible 4.0), and the majority of healthcare providers were supportive (66%, mean scores 3.6 to 4.0 out of possible 5). Conclusions: Auricular acupressure was successfully implemented within the standard of care for NOWS. Future studies should incorporate outlined suggestions and include qualitative measures of acceptance as well as randomized controlled trials to evaluate efficacy.
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Affiliation(s)
- Heather J Jackson
- Vanderbilt Ingram Cancer Center and Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cristina Lopez
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Sarah Miller
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Barbara Englehardt
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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Abstract
Alcohol, tobacco, and cannabis are the substances most frequently used during pregnancy, and opioid-exposed pregnancies have increased fourfold. The purpose of this review is to describe the prevalence and consequences of prenatal exposure to alcohol, tobacco, cannabis, and opioids. Currently available screening questionnaires for prenatal substance use are summarized and contrasted with the measures available for prenatal alcohol use. Because screening for prenatal alcohol and substance use is but the prelude to efforts to mitigate the potential adverse consequences, attempts for the modification of these consequences are briefly reviewed. In addition, areas of future research related to the criminalization of prenatal substance use, which may inhibit both inquiry and disclosure, are discussed. Indeed, the full potential of effective interventions has yet to be realized.
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Affiliation(s)
- Grace Chang
- U.S. Department of Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts
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Abstract
Pregnant and postpartum women with opiate use disorder present a challenge in perinatal care. It is important for health care teams to provide sensitive and compassionate evidence-based care for these women, who often are stigmatized during the prenatal, delivery, and postpartum periods. Women with opiate use disorder are at risk for inadequate prenatal and postpartum care and for complications. Infants are at risk for neonatal abstinence syndrome and are expected to require neonatal intensive care. Pain management during labor and for cesarean delivery requires consultation and collaboration with providers who have expertise in management of addiction. Postpartum follow-up is essential.
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Clemans-Cope L, Holla N, Lee HC, Cong AS, Castro R, Chyi L, Huang A, Taylor KJ, Kenney GM. Neonatal abstinence syndrome management in California birth hospitals: results of a statewide survey. J Perinatol 2020; 40:463-472. [PMID: 31911649 PMCID: PMC7042156 DOI: 10.1038/s41372-019-0568-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 11/22/2019] [Accepted: 12/18/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Assess management of neonatal abstinence syndrome (NAS) in California hospitals to identify potential opportunities to expand the use of best practices. STUDY DESIGN We fielded an internet-based survey of 37 questions to medical directors or nurse managers at 145 birth hospitals in California. RESULTS Seventy-five participants (52%) responded. Most respondents reported having at least one written protocol for managing NAS, but gaps included protocols for pharmacologic management. Newer tools for assessing NAS severity were not commonly used. About half reported usually or always using nonpharmacologic strategies; there is scope for increasing breastfeeding when recommended, skin-to-skin care, and rooming-in. CONCLUSIONS We found systematic gaps in care for infants with NAS in a sample of California birth hospitals, as well as opportunities to spread best practices. Adoption of new approaches will vary across hospitals. A concerted statewide effort to facilitate such implementation has strong potential to increase access to evidence-based treatment for infants and mothers.
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Affiliation(s)
- Lisa Clemans-Cope
- The Urban Institute, 500 L'Enfant Plaza SW, Washington, DC, 20037, USA.
| | - Nikhil Holla
- George Washington University, Washington, DC, USA
| | - Henry C Lee
- Division of Neonatal & Developmental Medicine, Stanford University, Stanford, CA, USA
| | - Allison Shufei Cong
- California Perinatal Quality Care Collaborative (CPQCC), Stanford University, Stanford, CA, USA
| | - Robert Castro
- Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa Chyi
- Walnut Creek Medical Center, Kaiser Northern California NAS Workgroup Co-chair, Walnut Creek, CA, USA
| | - Angela Huang
- Department of Neonatology, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Kimá Joy Taylor
- The Urban Institute, 500 L'Enfant Plaza SW, Washington, DC, 20037, USA
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Lamonica A, Boeri M. Stories of Loss: Separation of Children and Mothers Who Use Opioids. JOURNAL OF ETHNOGRAPHIC AND QUALITATIVE RESEARCH 2020; 15:63-81. [PMID: 34621462 PMCID: PMC8493853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
In the present article, we examine the experiences of women who use opioids and have lost children to governing agencies or family members with a focus on access to resources. We conducted 28 qualitative interviews with mothers who misused opioids and lost custody of their children. Their narratives are analyzed within a social capital framework. Mothers with both negative and positive social capital, whose children were removed, desired to regain their maternal role. However, mothers with negative social capital had increased difficulty navigating the judicial system and accessing needed services, were less likely to remain in treatment, more likely to use drugs, and less likely to regain custody of their children than women with positive social capital. We suggest that medical, social, and law enforcement agencies do more to link mothers who misuse opioids with positive social capital in order to increase their participation and retention in treatment and help keep families intact.
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Affiliation(s)
- Aukje Lamonica
- Southern Connecticut State University, Associate Professor of Public Health
| | - Miriam Boeri
- Bentley University, Associate Professor of Sociology
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Abstract
Opioid use and abuse have skyrocketed in the United States over the last decade. As a result, we have seen a substantial increase in neonates who are exposed to opioids in-utero. Anywhere from 55% to 94% of infants exposed to opioids will experience withdrawal, known as neonatal abstinence syndrome (NAS), and will require management of their symptoms in the hospital. It is important to know what to look for in an infant who is experiencing NAS, how to determine if treatment is needed and what type of treatment is indicated, and how to prepare the infant for discharge once they are stable. Unfortunately, there are no standardized care plans in place for the management of this population. Although assessment tools such as the Finnegan scoring systems are available, they are not validated and can be cumbersome and difficult to administer. Other methods of assessment are being studied and may prove to be more useful in the clinical setting of neonatal withdrawal. Neither nonpharmacologic nor pharmacologic interventions are standardized, with individual institutions determining their plan of care. Development of more standardized care could significantly improve the management of these patients. [Pediatr Ann. 2020;49(1):e3-e7.].
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Helme DW, Egan KL, Lukacena KM, Roberson L, Zelaya CM, McCleary MS, Wolfson M. Encouraging Disposal of Unused Opioid Analgesics in Appalachia. DRUGS (ABINGDON, ENGLAND) 2020; 27:407-415. [PMID: 35233152 DOI: 10.1080/09687637.2020.1711871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The Appalachian region has been disproportionately impacted by the opioid epidemic. This study, informed by the Health Belief Model (HBM), explored Appalachian community members' perspectives on prescription opioid misuse and community-based programs to dispose of unused opioid analgesics. In 2018, we conducted ten focus groups (n=94 participants) in 5 Appalachian counties. Thirteen themes across 5 of the HBM constructs emerged from our analysis. Participants perceived that their communities are susceptible to the harms associated with opioid misuse, these harms are serious, suggesting they could be motivated to change disposal behaviors. Many participants recognized the benefit to disposing of unused prescription opioids including protecting household members from misusing and protecting the home from robbery. Nevertheless, participants identified barriers to proper disposal, including keeping the medications "just in case" for future ailments and the location of drop boxes near law enforcement (due to deep-seated mistrust of law enforcement agencies). Self-efficacy was difficult to assess as many participants were completely unaware of the presence of dropboxes in the community and also expressed concerns about the inconvenience of proper disposal using dropboxes These findings have implications for developing community-based campaign messages promoting proper disposal of unused opioids.
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Affiliation(s)
| | - Kathleen L Egan
- Department of Health Education and Promotion, East Carolina University
| | | | | | | | | | - Mark Wolfson
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine
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McPhail BT, Emoto C, Fukuda T, Butler D, Wiles JR, Akinbi H, Vinks AA. Utilizing Pediatric Physiologically Based Pharmacokinetic Models to Examine Factors That Contribute to Methadone Pharmacokinetic Variability in Neonatal Abstinence Syndrome Patients. J Clin Pharmacol 2019; 60:453-465. [PMID: 31820437 DOI: 10.1002/jcph.1538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/09/2019] [Indexed: 12/30/2022]
Abstract
Chronic intrauterine exposure to psychoactive drugs often results in neonatal abstinence syndrome (NAS). NAS is the symptomatic drug withdrawal in newborns that generally occurs after in utero chronic opioid exposure. Methadone is an opioid analgesic commonly prescribed for pharmacologic management of NAS. It exhibits high pharmacokinetic (PK) variability. The current study used physiologically based PK modeling to predict the PK profile of methadone in 20 newborns treated for NAS. The physiologically based PK simulations adequately predicted the PK profile of the clinical data for 45% of the patients. Sensitivity analyses were conducted to explore contributing factors to methadone PK variability. The data suggest that P450 enzymatic activity impacts the clearance of methadone in virtual adults and neonates, while the contribution of cardiac output may be negligible. Understanding maturational and/or pharmacogenetic changes in cytochrome P450 enzymatic activity may further explain the large PK variability of methadone in newborns with NAS and will help individualized treatment.
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Affiliation(s)
- Brooks T McPhail
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA
| | - Chie Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dawn Butler
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Henry Akinbi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Perinatal Institute, Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Chang G, Ondersma SJ, Blake-Lamb T, Gilstad-Hayden K, Orav EJ, Yonkers KA. Identification of substance use disorders among pregnant women: A comparison of screeners. Drug Alcohol Depend 2019; 205:107651. [PMID: 31683243 DOI: 10.1016/j.drugalcdep.2019.107651] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study is to evaluate five self-report, non-proprietary questionnaires in the identification of substance use disorders [including alcohol, cannabis, opioids, and stimulants] among pregnant women. PROCEDURES A total of 1220 pregnant women completed the NIDA Quick Screen, CRAFFT, Substance Use Risk Profile-Pregnancy (SURP-P), Wayne Indirect Drug Use Questionnaire (WIDUS), and the 5 Ps, as well as the MINI diagnostic interview for substance use disorders, which served as the reference standard. Measures of merit calculated for each screener included sensitivity, specificity, accuracy, and area under the receiver operating curve (AUROC). MAIN FINDINGS The participants were socioeconomically diverse, with a mean age of 29 years. Over 15% met diagnostic criteria for a substance use disorder. AUROCS for identifying any substance use disorder (including alcohol) ranged from a high of 0.75 for the CRAFFT (95% CI = 0.72-79) and 0.74 for the SURP-P (95% CI = 0.71-.78) to a low of 0.62 for the NIDA Quick Screen (95% CI = 0.59-.65). Overall accuracy of most tested measures was higher for identification of alcohol use disorders than for other substance use disorders (e.g., AUROCs for the CRAFFT and SURP-P for identifying alcohol use disorders were 0.78 and 0.77, respectively). PRINCIPAL CONCLUSIONS The CRAFFT and SURP-P showed modest ability to identify substance use disorders among pregnant women. Future research is needed to develop an ideal questionnaire set in the complicated societal context which includes increasing rates of use and potential sanction.
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Affiliation(s)
- Grace Chang
- Department of Psychiatry, Harvard Medical School, Boston, MA, 02115, United States; VA Boston Healthcare System, Boston, MA, 02301, United States.
| | - Steven J Ondersma
- Merrill Palmer Skillman Institute and Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, 48202, United States
| | - Tiffany Blake-Lamb
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, 02114, United States; Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA, 02115, United States
| | - Kate Gilstad-Hayden
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, 06520, United States
| | - E John Orav
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, 02115, United States; Department of Medicine (Biostatistics), Harvard Medical School, Boston, MA, 02115, United States
| | - Kimberly A Yonkers
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, 06520, United States; Division of Chronic Disease, Yale University School of Epidemiology and Public Health, New Haven, CT, 06520, United States; Department of Obstetrics, Gynecology and Reproductive Medicine, Yale University School of Medicine, New Haven, CT, 06520, United States
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Abstract
In a number of countries, the prevalence of neonatal opioid withdrawal syndrome (NOWS) is increasing. While NOWS is ultimately the result of opioid exposure in utero, a wide range of risk factors have been associated with the prevalence of NOWS, extending beyond just drug exposure. This article reviews the available literature on factors associated with the incidence of NOWS in opioid-exposed neonates. A range of risk factors have been associated with NOWS, including features of neonatal drug exposure, maternal and neonatal characteristics, aspects of labor and delivery, and genetics. Increased length of gestation and higher birth weight were consistently associated with an increased risk of NOWS, while breast feeding and 'rooming-in' were associated with a reduced risk of NOWS. Additionally, several genetic factors have also been associated with NOWS severity. There is conflicting evidence on the association between NOWS and other risk factors including opioid dose, neonate sex, and the use of some medications during pregnancy. This may be in part attributable to differences in how NOWS is diagnosed and the variety of methodologies across studies. While a large number of risk factors associated with NOWS are non-modifiable, encouraging pregnant women to reduce other drug use (including smoking), breast feed their child, and the judicious use of medications during pregnancy may help reduce the prevalence of NOWS. The presence or absence of NOWS in an opioid-exposed neonate is associated with a wide range of factors. Some of these modifiable risk factors may be potential targets for the primary prevention of NOWS.
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Chiang KV, Okoroh EM, Kasehagen LJ, Garcia-Saavedra LF, Ko JY. Standardization of State Definitions for Neonatal Abstinence Syndrome Surveillance and the Opioid Crisis. Am J Public Health 2019; 109:1193-1197. [PMID: 31318590 PMCID: PMC6687235 DOI: 10.2105/ajph.2019.305170] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2019] [Indexed: 11/04/2022]
Abstract
Rates of neonatal abstinence syndrome (NAS) have increased fivefold in the past decade. To address this expanding and complex issue, state public health agencies have addressed the opioid crisis affecting newborns in diverse ways, leading to a variety of methods to quantify the burden of NAS.In an effort to understand this variability, we summarized clinical case and surveillance definitions used across jurisdictions in the United States. We confirmed that the rapid progression of the nation's opioid crisis resulted in heterogeneous processes for identifying NAS. Current clinical case definitions use different combinations of clinician-observed signs of withdrawal and evidence of perinatal substance exposure. Similarly, there is discordance in diagnosis codes used in surveillance definitions. This variability makes it difficult to produce comparable estimates across jurisdictions, which are needed to effectively guide public health strategies and interventions.Although standardization is complicated, consistent NAS definitions would increase comparability of NAS estimates across the nation and would better guide prevention and treatment efforts for women and their infants.
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Affiliation(s)
- Katelyn V Chiang
- At the time of the writing of this article, Katelyn V. Chiang, Ekwutosi M. Okoroh, Laurin J. Kasehagen, and Jean Y. Ko were with the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Ekwutosi M. Okoroh and Jean Y. Ko are with the US Public Health Service Commissioned Corps, Rockville, MD. Laurin J. Kasehagen is with the Vermont Department of Health and Vermont Department of Mental Health, Burlington. Luigi F. Garcia-Saavedra is with the New Mexico Department of Health, Santa Fe
| | - Ekwutosi M Okoroh
- At the time of the writing of this article, Katelyn V. Chiang, Ekwutosi M. Okoroh, Laurin J. Kasehagen, and Jean Y. Ko were with the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Ekwutosi M. Okoroh and Jean Y. Ko are with the US Public Health Service Commissioned Corps, Rockville, MD. Laurin J. Kasehagen is with the Vermont Department of Health and Vermont Department of Mental Health, Burlington. Luigi F. Garcia-Saavedra is with the New Mexico Department of Health, Santa Fe
| | - Laurin J Kasehagen
- At the time of the writing of this article, Katelyn V. Chiang, Ekwutosi M. Okoroh, Laurin J. Kasehagen, and Jean Y. Ko were with the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Ekwutosi M. Okoroh and Jean Y. Ko are with the US Public Health Service Commissioned Corps, Rockville, MD. Laurin J. Kasehagen is with the Vermont Department of Health and Vermont Department of Mental Health, Burlington. Luigi F. Garcia-Saavedra is with the New Mexico Department of Health, Santa Fe
| | - Luigi F Garcia-Saavedra
- At the time of the writing of this article, Katelyn V. Chiang, Ekwutosi M. Okoroh, Laurin J. Kasehagen, and Jean Y. Ko were with the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Ekwutosi M. Okoroh and Jean Y. Ko are with the US Public Health Service Commissioned Corps, Rockville, MD. Laurin J. Kasehagen is with the Vermont Department of Health and Vermont Department of Mental Health, Burlington. Luigi F. Garcia-Saavedra is with the New Mexico Department of Health, Santa Fe
| | - Jean Y Ko
- At the time of the writing of this article, Katelyn V. Chiang, Ekwutosi M. Okoroh, Laurin J. Kasehagen, and Jean Y. Ko were with the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Ekwutosi M. Okoroh and Jean Y. Ko are with the US Public Health Service Commissioned Corps, Rockville, MD. Laurin J. Kasehagen is with the Vermont Department of Health and Vermont Department of Mental Health, Burlington. Luigi F. Garcia-Saavedra is with the New Mexico Department of Health, Santa Fe
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Larson JJ, Graham DL, Singer LT, Beckwith AM, Terplan M, Davis JM, Martinez J, Bada HS. Cognitive and Behavioral Impact on Children Exposed to Opioids During Pregnancy. Pediatrics 2019; 144:peds.2019-0514. [PMID: 31320466 PMCID: PMC10106099 DOI: 10.1542/peds.2019-0514] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 11/24/2022] Open
Abstract
The developmental impact of opioid use during pregnancy is a subject of ongoing debate. Short-term neonatal outcomes, such as lower birth weight and neonatal abstinence syndrome, are the most well-recognized outcomes. However, knowledge gaps exist regarding longer-term neurocognitive and mental health outcomes. In this article, we summarize an expert panel discussion that was held in April 2018 by the Substance Abuse and Mental Health Services Administration and attended by national experts in the field of perinatal opioid exposure and its impact on child development. Despite the challenges with research in this area, there is emerging literature revealing an association between neonates exposed to opioids in utero and longer-term adverse neurocognitive, behavioral, and developmental outcomes. Although adverse sequalae may not be apparent in the neonatal period, they may become more salient as children develop and reach preschool and school age. Multiple variables (genetic, environmental, and biological) result in a highly complex picture. The next steps and strategies to support families impacted by opioid use disorder are explored. Model programs are also considered, including integrated care for the child and mother, parenting supports, and augmentations to home visiting.
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Affiliation(s)
- Justine J Larson
- Substance Abuse and Mental Health Services Administration, Rockville, Maryland;
| | - Devon L Graham
- College of Medicine, Florida State University, Tallahassee, Florida
| | | | | | - Mishka Terplan
- School of Medicine, Tufts University, Boston, Massachusetts
| | | | - Juan Martinez
- School of Public Health, University of Colorado Denver, Denver, Colorado; and
| | - Henrietta S Bada
- College of Medicine, University of Kentucky, Lexington, Kentucky
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Cook CE, Fantasia HC. Interventions for the Treatment of Neonatal Abstinence Syndrome. Nurs Womens Health 2019; 23:357-365. [PMID: 31251931 DOI: 10.1016/j.nwh.2019.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/06/2019] [Accepted: 05/01/2019] [Indexed: 06/09/2023]
Abstract
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.
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Neonatal Abstinence Syndrome: An Integrative Review of Neonatal Acupuncture to Inform a Protocol for Adjunctive Treatment. Adv Neonatal Care 2019; 19:165-178. [PMID: 31140978 DOI: 10.1097/anc.0000000000000630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The current opioid epidemic in the United States has given rise to a growing incidence of neonatal abstinence syndrome (NAS). Treatments for this condition optimize nonpharmacologic therapies in an effort to improve withdrawal symptoms and reduce or eliminate the need for opioid medications, thereby reducing hospital length of stay and improving healthy neonatal outcomes. PURPOSE The purpose of this review was to evaluate the current evidence for neonatal acupuncture treatments and identify essential characteristics that must be included in a treatment protocol for NAS. METHODS/SEARCH STRATEGY An integrative review was conducted under the guidance of the Whittemore and Knafl methodology and near-term infant conceptual framework. An evaluation of the quality and levels of evidence was also included. FINDINGS/RESULTS A total of 10 studies were identified in this review. Four of these studies were randomized controlled trials, and utilized acupuncture in the neonatal population to evaluate impact on pain, NAS, and weight gain. IMPLICATIONS FOR PRACTICE This review provided the essential elements for the development of a complementary acupuncture treatment protocol for the management of NAS. IMPLICATIONS FOR RESEARCH Future research should include the identified essential characteristics in high-quality, blinded, randomized controlled trials to assess the treatment effect of acupuncture on neonates experiencing withdrawal symptoms.
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Zakerabasali S, Safdari R, Kadivar M, Rostam Niakan Kalhori S, Mokhtaran M, Karbasi Z, Sayarifard A, Abhari S. Neonatal abstinence syndrome: a systematic review of current databases and registries. J Matern Fetal Neonatal Med 2019; 34:979-992. [PMID: 31092074 DOI: 10.1080/14767058.2019.1618827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Registries are considered as rich sources of data for determination of infants with neonatal abstinence syndrome (NAS), the improvement of provided care and research. The aims of this study were: (1) to investigate the existing studies including NAS registries, (2) to identify and extract the required data elements. METHODS The following electronic databases were searched: PubMed, Scopus, Web of Science, ProQuest, Embase/Medline, and Psych Info. In addition, a review of gray literature was undertaken to identify relevant studies in English covering the period from 1 January 2009 to 1 November 2018 including registries and databases. Screening of titles, abstracts, and full-texts were conducted independently by two researchers based on PRISMA guidelines. The basic registry information, scope, registry type, data source, the purpose of registry, important variables were extracted and analyzed. RESULTS Twenty-five articles were eligible and included in the review; they reported 37 registries and databases related to NAS at the national and state levels in 11 countries from 1876 to 2013. We proposed a NAS registry design framework based on well-known data-information-knowledge (DIK) structure due to Ackoff's DIK hierarchy has a defined role as a central model of information systems, information management, and knowledge management. CONCLUSIONS To the best of our knowledge, this is the first study which has systematically reviewed NAS-related registries. Since there are no international standards to develop new NAS registries, the proposed framework in this article can be beneficial. This framework is essential not only to facilitate the NAS registry design but also to help the collection of high-value clinical data necessary for the acquisition of better clinical knowledge.
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Affiliation(s)
- Somayyeh Zakerabasali
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Safdari
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Maliheh Kadivar
- Department of Pediatrics, Division of Neonatology, Tehran University of Medical Sciences, Tehran, Iran.,Community Based Participatory Research Center, Iranian Institute for Reduction of High-Risk Behaviors, Tehran, Iran
| | - Sharareh Rostam Niakan Kalhori
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Zahra Karbasi
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Azadeh Sayarifard
- Community Based Participatory Research Center, Iranian Institute for Reduction of High-Risk Behaviors, Tehran, Iran
| | - Shahabeddin Abhari
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
Tens of thousands of infants are impacted yearly by prenatal opioid exposure. The term neonatal opioid withdrawal syndrome (NOWS) is now replacing the more familiar term neonatal abstinence syndrome (NAS). Ongoing debate continues related to standard regimens for treatment of this oftentimes perplexing condition. Historically, treatment has focused on pharmacologic interventions. However, there is limited research that points to nonpharmacologic methods of treatment as viable options, whether alone or in addition to pharmacologic interventions. This article, utilizing a review of pertinent literature, outlines the physical aspects of NOWS, including its pathophysiology and the resulting physical clinical signs. In addition, we present an overview of how age-appropriate, nonpharmacologic interventions, centered on developmental care, may be a valuable approach to organize and prioritize routine care for these infants, their families, and the health care team facing the challenges of NOWS. Finally, the need for further research to better define evidence-based standards of care for these infants and their families is discussed.
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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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Parikh JM, Amolenda P, Rutledge J, Szabova A, Vidya Chidambaran. An update on the safety of prescribing opioids in pediatrics. Expert Opin Drug Saf 2019; 18:127-143. [PMID: 30650988 PMCID: PMC6446903 DOI: 10.1080/14740338.2019.1571037] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/14/2019] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The opioid abuse epidemic and its toll on the adolescent population have heightened awareness for safer opioid prescribing practices in pediatric pain management. Opioids remain the mainstay of therapy for severe pain, although there is an emphasis on multimodal therapy. Areas covered: In this update, the authors present information on parenteral/oral opioids commonly used in pediatrics. Recommendations for opioid use in special circumstances including neonates and developmental pharmacokinetic concerns are discussed. Due to noticeable interindividual variability, pharmacogenomics may be important for tailoring pain regimens. In particular, the role of CYP2D6 phenotypes on opioid selection/dosing and clinical implications are discussed. A summary of adverse effects and opioid safety data, and the role of regulations, risk assessment, Centers for Disease Control and Prevention guidelines, follow-up, and monitoring for compliance in opioid prescribing, are detailed. Expert opinion: 'One size does not fit all' describes the need for public policies focused on pediatric pain and opioid use, as children are not 'little adults.' Clinical trials to evaluate pharmacokinetics-pharmacodynamics of opioids are currently lacking. Development of novel biased opioid agonists, clinical integration of genetics in informed decision-making, and emphasis on top-down approaches to pain management will be key to decrease opioid reliance.
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Associations between Orofacial Clefting and Neonatal Abstinence Syndrome. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2095. [PMID: 30859050 PMCID: PMC6382228 DOI: 10.1097/gox.0000000000002095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 11/07/2018] [Indexed: 12/21/2022]
Abstract
Background: Orofacial clefting (OFC) is the most common developmental craniofacial malformation, and causal etiologies largely remain unknown. The opioid crisis has led to a large proportion of infants recovering from neonatal abstinence syndrome (NAS) due to in-utero narcotics exposure. We sought to characterize the prevalence of OFC in infants with NAS. Methods: This cohort study analyzed live births at our institution from 2013 to 2017 to identify any association between OFC and NAS. Results: Prevalence of OFC was 6.79 and 1.63 (per 1,000 live births) in the NAS and general population, respectively. Odds ratios for NAS patients having developed OFC, isolated cleft palate, isolated cleft lip, and combined cleft lip and palate compared with the general population were found to be 4.18 (P = 0.001), 5.92 (P = 0.001), 3.79 (P = 0.05), and 2.94 (P = 0.35), respectively. Analyses performed comparing the NAS and general populations to control for potential confounding variables influencing the NAS population yielded no significant differences with exception of in-utero exposure to physician prescribed opioids. Conclusions: Prevalence of OFC in infants with NAS was higher than the general live birth population. Isolated cleft palate and isolated cleft lip, specifically, were significantly more prevalent in NAS patients compared with the general population and were associated with in-utero opioid exposure.
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Friedman H, Parkinson G, Tighiouart H, Parkinson C, Tybor D, Terrin N, Lester B, Harvey-Wilkes K, Davis JM. Pharmacologic treatment of infants with neonatal abstinence syndrome in community hospitals compared to academic medical centers. J Perinatol 2018; 38:1651-1656. [PMID: 30237476 DOI: 10.1038/s41372-018-0230-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/19/2018] [Accepted: 08/23/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare length of hospital stay (LOS), LOS due to neonatal abstinence syndrome (NAS), and duration of pharmacologic treatment in community or academic settings. STUDY DESIGN One hundred-two infants exposed to opioids in utero at two community hospitals were compared to 256 from eight academic centers. All infants were managed with non-pharmacologic care followed by similar pharmacologic treatment options. RESULTS Two hundred-twelve infants received pharmacologic treatment for NAS. Mean LOS (24.7 ± 8.5 vs. 24.5 ± 11.3 days), LOS due to NAS (24.0 ± 8.2 vs. 23.3 ± 9.2 days), and duration of NAS treatment (19.3 ± 8.0 vs. 18.9 ± 9.2 days) were similar in community compared to academic medical centers. CONCLUSIONS No significant differences were found in infants managed in the community compared to academic care settings. These findings support caring for opioid-exposed infants in both community and academic settings with the use of standardized care protocols.
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Affiliation(s)
- Hayley Friedman
- Division of Newborn Medicine, Tufts Medical Center, Boston, MA, USA
| | | | - Hocine Tighiouart
- The Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA.,The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | | | - David Tybor
- School of Public Health, Tufts University School of Medicine, Boston, MA, USA
| | - Norma Terrin
- The Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - Barry Lester
- Department of Pediatrics, Women and Infant's Hospital, Providence, RI, USA
| | | | - Jonathan M Davis
- Division of Newborn Medicine, Tufts Medical Center, Boston, MA, USA. .,The Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA.
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Syvertsen JL, Toneff H, Madden DR, Clapp JD. Conceptualizing Neonatal Abstinence Syndrome as a Cascade of Care: A Qualitative Study With Healthcare Providers in Ohio. Adv Neonatal Care 2018; 18:488-499. [PMID: 30234507 DOI: 10.1097/anc.0000000000000552] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The opioid epidemic remains a serious issue in the United States and presents additional challenges for women of childbearing age. An increasingly common complication of opioid use is neonatal abstinence syndrome (NAS), or infant withdrawal from in utero exposure to opioids. PURPOSE The objective of our qualitative study was to identify service needs and barriers to care in the NAS epidemic in Ohio, which has among the highest rates of opioid use and NAS in the nation. METHODS Drawing on interviews with 18 healthcare providers, we investigated the challenges, opportunities, and service gaps in treating NAS. Open-ended questions covered opioid misuse and drug treatment, provision of and barriers to healthcare, and suggestions to improve prevention and programming. Content analysis identified major themes. FINDINGS Providers were primarily women (67%) and included individuals working in healthcare administrative positions, hospital settings, clinics, and social support positions for pregnant women or new mothers. Our results suggest that rather than an acute diagnosis, NAS is better conceptualized as a "cascade of care" including (1) prevention, (2) prenatal care, including drug treatment, (3) labor and delivery, and (4) aftercare. Providers identified challenges and opportunities at each stage of the cascade that could influence NAS outcomes. IMPLICATIONS FOR PRACTICE Our results suggest that greater resources, coordination, and cross-disciplinary education are urgently needed across the cascade of care to effectively address NAS. IMPLICATIONS FOR RESEARCH Framing NAS as a cascade of care allows researchers to identify points along a cascade where mothers and infants require enhanced care and access to social and health services.
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Uusküla A, Raag M, Vorobjov S, Jarlais DD. Another frontier for harm reduction: contraceptive needs of females who inject drugs in Estonia, a cross-sectional study. Harm Reduct J 2018; 15:10. [PMID: 29506538 PMCID: PMC5838942 DOI: 10.1186/s12954-018-0215-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 02/21/2018] [Indexed: 01/04/2023] Open
Abstract
Background Despite increasing contraceptive availability, unintended pregnancy remains a global problem. Developing strategies to reverse this trend and increasing occurrence of withdrawal syndrome among newborn children of females currently injecting drugs warrants special attention. The knowledge base on the uptake of effective contraception among females who inject drugs (FWID) is scant. We aimed to examine the prevalence of and factors associated with the use of non-condom contraceptives among sexually active FWID with the focus on effective contraception. Methods In a series of cross-sectional studies (2007–2013), 265 current FWID were recruited through respondent-driven sampling (RDS), interviewed, and tested for HIV. RDS weights were used to estimate the prevalence of effective contraception (hormonal contraception, intrauterine device, sterilization) use in the last 6 months. Results Of the sexually active women with main partners (n = 196) 4.8% (95% CI 2.3–9.7) were using effective contraception, 52.7% (95% CI 42.5–62.7) less-effective or no contraception. 42.5% (95% CI 32.7–52.9) relied on condoms for contraception. The odds for using effective contraception were higher among women with > 10 years of education (OR 7.29, 95% CI 1.4–38.8). None of the women lacking health insurance (n = 84) were using effective contraception. Conclusions The very low coverage with effective contraception highlights the need to improve contraceptive services for FWID. Reproductive health service including contraception should be considered essential components of harm reduction and of comprehensive prevention and care for HIV among persons who use drugs.
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Affiliation(s)
- Anneli Uusküla
- Department of Family medicine and Public Health, University of Tartu, Ravila 19, 50411, Tartu, Estonia.
| | - Mait Raag
- Department of Family medicine and Public Health, University of Tartu, Ravila 19, 50411, Tartu, Estonia
| | - Sigrid Vorobjov
- Infectious Diseases and Drug Monitoring Department, National Institute for Health Development, Tallinn, Estonia
| | - Don Des Jarlais
- Department of Psychiatry, The Baron Edmond de Rothschild Chemical Dependency Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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