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Kain S, Newby B. Neonatal Abstinence Syndrome: A Review of Treatment in the Neonatal Intensive Care Unit. Can J Hosp Pharm 2023; 76:234-238. [PMID: 37409149 PMCID: PMC10284283 DOI: 10.4212/cjhp.3381] [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: 07/07/2023]
Abstract
Background Neonatal abstinence syndrome (NAS) is a collection of symptoms that neonates may experience following antenatal exposure to substances that induce withdrawal. Optimal management remains unknown, and there is variation in management and outcomes. Objectives To describe the management, length of hospitalization, and adverse events in near-term and full-term neonates with NAS for whom treatment (pharmacotherapy and/or supportive care) was initiated in the neonatal intensive care unit (NICU). Methods A chart review was conducted of neonates admitted to the NICU of Surrey Memorial Hospital, Surrey, British Columbia, who received treatment for NAS between September 1, 2016, and September 1, 2021. Results A total of 48 neonates met the inclusion criteria. Opioids represented the most frequent type of antenatal exposure. Polysubstance exposures occurred in 45 (94%) of the neonates. Morphine was given to 29 (60%) of the neonates, and phenobarbital to 6 (13%); 5 of these neonates received both medications. The average duration of morphine treatment was 14 days, and the average length of hospitalization (all patients) was 16 days. All of the neonates experienced adverse events; in particular, 9 (30%) of the 30 who received pharmacotherapy were too sedated to feed, compared with 0% of the 18 with no pharmacotherapy. Conclusions The common finding of polysubstance antenatal exposure, involving predominantly opioids, was associated with scheduled morphine pharmacotherapy for the majority of patients, prolonged hospitalization, and frequent adverse events. Pharmacotherapy for NAS was associated with levels of sedation that interfered with feeding in neonates.
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Affiliation(s)
- Sarah Kain
- , BSc, PharmD, ACPR, is with Lower Mainland Pharmacy Services and the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia; and the Neonatal and Pediatric Pharmacy, Surrey Memorial Hospital, Surrey, British Columbia
| | - Brandi Newby
- , BScPharm, ACPR, is with Lower Mainland Pharmacy Services and the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia; and the Neonatal and Pediatric Pharmacy, Surrey Memorial Hospital, Surrey, British Columbia
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Bloch-Salisbury E, Wilson JD, Rodriguez N, Bruch T, McKenna L, Derbin M, Glidden B, Ayturk D, Aurora S, Yanowitz T, Barton B, Vining M, Beers SR, Bogen DL. Efficacy of a Vibrating Crib Mattress to Reduce Pharmacologic Treatment in Opioid-Exposed Newborns: A Randomized Clinical Trial. JAMA Pediatr 2023; 177:665-674. [PMID: 37184872 PMCID: PMC10186209 DOI: 10.1001/jamapediatrics.2023.1077] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/09/2023] [Indexed: 05/16/2023]
Abstract
Importance Pharmacologic agents are often used to treat newborns with prenatal opioid exposure (POE) despite known adverse effects on neurodevelopment. Alternative nonpharmacological interventions are needed. Objective To examine efficacy of a vibrating crib mattress for treating newborns with POE. Design, Setting, and Participants In this dual-site randomized clinical trial, 208 term newborns with POE, enrolled from March 9, 2017, to March 10, 2020, were studied at their bedside throughout hospitalization. Interventions Half the cohort received treatment as usual (TAU) and half received standard care plus low-level stochastic (random) vibrotactile stimulation (SVS) using a uniquely constructed crib mattress with a 3-hour on-off cycle. Study initiated in the newborn unit where newborns were randomized to TAU or SVS within 48 hours of birth. All infants whose symptoms met clinical criteria for pharmacologic treatment received morphine in the neonatal intensive care unit per standard care. Main Outcomes and Measures The a priori primary outcomes analyzed were pharmacotherapy (administration of morphine treatment [AMT], first-line medication at both study sites [number of infants treated], and cumulative morphine dose) and hospital length of stay. Intention-to-treat analysis was conducted. Results Analyses were performed on 181 newborns who completed hospitalization at the study sites (mean [SD] gestational age, 39.0 [1.2] weeks; mean [SD] birth weight, 3076 (489) g; 100 [55.2%] were female). Of the 181 analyzed infants, 121 (66.9%) were discharged without medication and 60 (33.1%) were transferred to the NICU for morphine treatment (31 [51.7%] TAU and 29 [48.3%] SVS). Treatment rate was not significantly different in the 2 groups: 35.6% (31 of 87 infants who received TAU) and 30.9% (29 of 94 infants who received SVS) (P = .60). Adjusting for site, sex, birth weight, opioid exposure, and feed type, infant duration on the vibrating mattress in the newborn unit was associated with reduction in AMT (adjusted odds ratio, 0.88 hours per day; 95% CI, 0.81-0.93 hours per day). This translated to a 50% relative reduction in AMT for infants who received SVS on average 6 hours per day. Among 32 infants transferred to the neonatal intensive care unit for morphine treatment who completed treatment within 3 weeks, those assigned to SVS finished treatment nearly twice as fast (hazard ratio, 1.96; 95% CI, 1.01-3.81), resulting in 3.18 fewer treatment days (95% CI, -0.47 to -0.04 days) and receiving a mean 1.76 mg/kg less morphine (95% CI, -3.02 to -0.50 mg/kg) than the TAU cohort. No effects of condition were observed among infants treated for more than 3 weeks (n = 28). Conclusions and Relevance The findings of this clinical trial suggest that SVS may serve as a complementary nonpharmacologic intervention for newborns with POE. Reducing pharmacotherapy with SVS has implications for reduced hospitalization stays and costs, and possibly improved infant outcomes given the known adverse effects of morphine on neurodevelopment. Trial Registration ClinicalTrials.gov Identifier: NCT02801331.
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Affiliation(s)
- Elisabeth Bloch-Salisbury
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - James D. Wilson
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nicolas Rodriguez
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Tory Bruch
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lauren McKenna
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Matthew Derbin
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Barbara Glidden
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Didem Ayturk
- Department of Quantitative and Health Sciences, University of Massachusetts Chan School of Medicine, Worcester
| | - Sanjay Aurora
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Toby Yanowitz
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bruce Barton
- Department of Quantitative and Health Sciences, University of Massachusetts Chan School of Medicine, Worcester
| | - Mark Vining
- Department of Pediatrics, University of Massachusetts Chan School of Medicine, Worcester
| | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Debra L. Bogen
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Abstract
Supplemental digital content is available in the text. Background Neonatal abstinence syndrome (NAS) rates have dramatically increased. Breastfeeding is a nonpharmacological intervention that may be beneficial, reducing NAS symptom severity and thus the need for and duration of pharmacological treatment and length of hospital stay. Objectives Conduct meta-analysis to determine whether breastfeeding results in better outcomes for NAS infants. Variables included symptom severity, need for and duration of pharmacological treatment, and length of hospital stay. Methods PubMed, Scopus, Embase, and Cochrane Library were searched from 2000 to 2020, and comparative studies examining breastfeeding for NAS infants were extracted. Randomized trials and cohort studies were included. Data were extracted and evaluated with Review Manager Version 5.3. A random-effects model was used to pool discontinuous outcomes using risk ratio and 95% confidence intervals. Continuous outcomes were evaluated by mean differences and 95% confidence intervals. Results Across 11 studies, 6,375 neonates were included in the meta-analysis. Using a random-effects analysis, breastfeeding reduced initiation of pharmacological treatment, reduced duration of pharmacological treatment, and reduced length of stay. No differences were detected for severity of NAS symptoms. Most studies only reported one to two variables of interest. For most studies, these variables were not the primary study outcomes. All studies were found to be of low risk and good quality based on the Cochrane Risk Assessment Tools. Varying breastfeeding definitions limit generalizability. Discussion Breastfeeding is associated with decreased initiation and duration of pharmacological treatment and length of stay.
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Economic Evaluation of Interventions for Treatment of Neonatal Opioid Withdrawal Syndrome: A Review. CHILDREN-BASEL 2021; 8:children8070534. [PMID: 34201863 PMCID: PMC8306925 DOI: 10.3390/children8070534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/18/2021] [Accepted: 06/19/2021] [Indexed: 11/17/2022]
Abstract
This study assessed the economic evidence on the pharmacological and non-pharmacological management of infants with neonatal opioid withdrawal syndrome (NOWS). Six databases were searched up to October 2020 for peer-reviewed studies. After titles and abstracts were screened, 79 studies remained for full-text review, and finally, 8 studies were eligible for inclusion in the review. The methodological quality of included studies was assessed using the Drummond checklist. The review showed significant limitations in these studies, with one study being rated as good and the remaining seven studies as of poor quality. There are methodological issues that require addressing, including a lack of detail on cost categories, a robust investigation of uncertainty, and extending the time horizon to consider longer-term outcomes beyond the initial birth hospitalization. Despite these limitations, existing evidence suggests non-pharmacological strategies such as rooming-in were associated with a shorter hospital stay and a decreased need for pharmacological treatment, thereby lowering hospitalization costs. The review highlights the paucity of high-quality studies assessing the cost-effectiveness of intervention strategies for NOWS. There is also a lack of evidence on long-term outcomes associated with NOWS and the treatment of NOWS. The inclusion of economic analyses in future studies will provide evidence to inform policymakers on resource allocation decisions for this patient population.
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Oji-Mmuo CN, Jones AN, Wu EY, Speer RR, Palmer T. Clinical care of neonates undergoing opioid withdrawal in the immediate postpartum period. Neurotoxicol Teratol 2021; 86:106978. [PMID: 33838247 DOI: 10.1016/j.ntt.2021.106978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 02/15/2021] [Accepted: 03/30/2021] [Indexed: 11/19/2022]
Abstract
As the opioid epidemic escalates in westernized countries around the world, chronic opioid use during pregnancy has become a growing public health issue. There are increasing concerns that chronic maternal opioid use might adversely affect the developing fetal brain. Furthermore, the sudden discontinuation of the trans-placental opioid supply at birth puts newborns at acute risk for neonatal opioid withdrawal syndrome (NOWS). NOWS is a multi-system disorder that has been identified in approximately 50-80% of neonates exposed to opioids due to chronic maternal use. Clinically, NOWS affects the central and autonomic nervous systems as well as the gastrointestinal and respiratory tracts. The clinical features of NOWS include hyperirritability, high-pitched crying, restlessness, tremors, poor sleep, agitation, seizures, sweating, fever, poor feeding, regurgitation, diarrhea, and tachypnea. NOWS is currently diagnosed using a clinical scoring tool followed by toxicological confirmation of the presence of opioids in meconium or tissue specimens. The first-line treatments for NOWS are non-pharmacologic comfort measures. If these measures fail, neonates may be treated with opioids and/or sedatives. Since the severity of NOWS can be highly variable, it is quite difficult to predict which opioid-exposed neonates will require pharmacotherapy and prolonged hospitalization. Factors associated with maternal polysubstance use, including the use of illicit substances and tobacco, have been associated with the increased severity and duration of NOWS. Since neonates with NOWS are at increased risk for long-term adverse neurodevelopmental outcomes, ongoing monitoring beyond the neonatal period is essential.
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Affiliation(s)
- Christiana N Oji-Mmuo
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State College of Medicine, Hershey, PA, USA.
| | - Antoinette N Jones
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Emma Y Wu
- Penn State College of Medicine, Hershey, PA, USA
| | - Rebecca R Speer
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy Palmer
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State College of Medicine, Hershey, PA, USA
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Isaac L, van den Hoogen NJ, Habib S, Trang T. Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences. J Neurosci Res 2021; 100:373-395. [PMID: 33675100 DOI: 10.1002/jnr.24811] [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: 01/20/2021] [Accepted: 02/01/2021] [Indexed: 11/12/2022]
Abstract
Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.
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Affiliation(s)
- Lisa Isaac
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nynke J van den Hoogen
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
| | - Sharifa Habib
- Department of Neonatology, Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Tuan Trang
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
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7
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Merhar SL, Ounpraseuth S, Devlin LA, Poindexter BB, Young LW, Berkey SD, Crowley M, Czynski AJ, Kiefer AS, Whalen BL, Das A, Fuller JF, Higgins RD, Thombre V, Lester BM, Smith PB, Newman S, Sánchez PJ, Smith MC, Simon AE. Phenobarbital and Clonidine as Secondary Medications for Neonatal Opioid Withdrawal Syndrome. Pediatrics 2021; 147:e2020017830. [PMID: 33632932 PMCID: PMC7919109 DOI: 10.1542/peds.2020-017830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the neonatal opioid withdrawal syndrome (NOWS) epidemic in the United States, evidence is limited for pharmacologic management when first-line opioid medications fail to control symptoms. The objective with this study was to evaluate outcomes of infants receiving secondary therapy with phenobarbital compared with clonidine, in combination with morphine, for the treatment of NOWS. METHODS We performed a retrospective cohort study of infants with NOWS from 30 hospitals. The primary outcome measures were the length of hospital stay, duration of opioid treatment, and peak morphine dose. Outcomes were compared by group by using analysis of variance and multivariable linear regression controlling for relevant confounders. RESULTS Of 563 infants with NOWS treated with morphine, 32% (n = 180) also received a secondary medication. Seventy-two received phenobarbital and 108 received clonidine. After adjustment for covariates, length of hospital stay was 10 days shorter, and, in some models, duration of morphine treatment was 7.5 days shorter in infants receiving phenobarbital compared with those receiving clonidine, with no difference in peak morphine dose. Infants were more likely to be discharged from the hospital on phenobarbital than clonidine (78% vs 29%, P < .0001). CONCLUSIONS Among infants with NOWS receiving morphine and secondary therapy, those treated with phenobarbital had shorter length of hospital stay and shorter morphine treatment duration than clonidine-treated infants but were discharged from the hospital more often on secondary medication. Further investigation is warranted to determine if the benefits of shorter hospital stay and shorter duration of morphine therapy justify the possible neurodevelopmental consequences of phenobarbital use in infants with NOWS.
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Affiliation(s)
- Stephanie L Merhar
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio;
| | - Songthip Ounpraseuth
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Lori A Devlin
- Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - Brenda B Poindexter
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Leslie W Young
- Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Sean D Berkey
- Alaska Native Tribal Health Consortium, Anchorage, Alaska
| | - Moira Crowley
- Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Adam J Czynski
- Department of Pediatrics, Women and Infant's Hospital, Providence, Rhode Island
| | - Autumn S Kiefer
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Bonny L Whalen
- Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Abhik Das
- RTI International, Rockville, Maryland
| | - Janell F Fuller
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Rosemary D Higgins
- National Institute of Child Health and Human Development, Bethesda, Maryland and George Mason University, Fairfax, Virginia
| | - Vaishali Thombre
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Barry M Lester
- Center for the Study of Children at Risk, Department of Pediatrics, Brown Alpert Medical School and Women and Infants Hospital, Providence, Rhode Island
| | - P Brian Smith
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
| | | | - Pablo J Sánchez
- Nationwide Children's Hospital, College of Medicine, The Ohio State University, Columbus, Ohio
| | - M Cody Smith
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, West Virginia; and
| | - Alan E Simon
- Environmental Influences on Child Health Outcomes Program, Office of the Director, National Institutes of Health, Rockville, Maryland
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Brusseau C, Burnette T, Heidel RE. Clonidine versus phenobarbital as adjunctive therapy for neonatal abstinence syndrome. J Perinatol 2020; 40:1050-1055. [PMID: 32424335 DOI: 10.1038/s41372-020-0685-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/06/2020] [Accepted: 04/30/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare clonidine versus phenobarbital as adjunctive therapy in infants who failed monotherapy with morphine for neonatal abstinence syndrome (NAS). STUDY DESIGN Prospective, randomized, open-label study of infants ≥ 35 weeks' gestation. Infants received clonidine or phenobarbital per protocol. Primary outcome was morphine treatment days. Secondary outcomes were inpatient adjunctive days, length of stay (LOS), triple therapy, safety, and readmission rates. RESULTS A total of 25 infants were treated with clonidine (n = 14) or phenobarbital (n = 11). Mean morphine treatment duration was significantly longer with clonidine (34.4 days, SD = 10.6) compared with phenobarbital (25.5 days, SD = 7.3, p = 0.026). The clonidine group also had higher inpatient adjunctive days (mean: 33.8 days [SD = 14.3] vs. 22 days [SD = 12.6], p = 0.042) and LOS (mean: 41.8 days [SD = 10.9] vs. 31 days [SD = 10]; p = 0.018) compared with phenobarbital. CONCLUSIONS Phenobarbital, as adjunctive therapy, led to significantly shorter duration of morphine therapy, inpatient adjunctive days, and length of stay compared with clonidine.
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Affiliation(s)
- Carrie Brusseau
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA.
| | - Tara Burnette
- Department of Neonatology, University of Tennessee Medical Center, Knoxville, TN, USA
| | - R Eric Heidel
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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Frazier LM, Bobby LE, Gawronski KM. Emerging therapies for the treatment of neonatal abstinence syndrome. J Matern Fetal Neonatal Med 2020; 35:987-995. [PMID: 32146833 DOI: 10.1080/14767058.2020.1733522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: To examine the evidence for emerging treatment options, buprenorphine or clonidine, as monotherapy for the treatment of neonatal abstinence syndrome (NAS) against standards of care, morphine or methadone.Data sources: A PubMed literature search from 1946 to 2019 was performed using the terms NAS, neonatal withdrawal, buprenorphine and NAS, clonidine and NAS, morphine and NAS, methadone and NAS, opioids and pregnancy, opioids and NAS, prenatal exposure and opioids.Study selection and data extraction: Study evaluation was limited to English-language studies conducted in humans. Articles were eliminated if subjects did not have a formal diagnosis of NAS. Additionally, studies were eliminated if neonates received diluted tincture of opium. Additional references were identified from a manual citation review.Relevance to patient care and clinical practice: Eight articles were evaluated. Five articles compared buprenorphine to either morphine or methadone. Buprenorphine was found to decrease length of NAS treatment an average of 9.2 days and decrease hospital length of stay (LOS) an average of 8.2 days. Three articles evaluated the use of clonidine for NAS, two as an adjunct to morphine and one as monotherapy. Adjunctive clonidine plus morphine versus phenobarbital plus morphine both significantly reduced the total morphine treatment duration; however, patients remained on adjunctive phenobarbital significantly longer than clonidine. As monotherapy, clonidine was found to decrease NAS treatment an average of 11 days and decrease overall LOS an average of six days compared to morphine treatment.Conclusion: Treatment with buprenorphine or clonidine has shown favorable effects by reducing length of NAS treatment and LOS. These emerging therapies may be as effective as morphine or methadone for NAS, in combination with nonpharmacologic strategies. Long-term follow-up is needed.
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Affiliation(s)
- Lexus M Frazier
- School of Pharmacy, Lake Erie College of Osteopathic Medicine, Erie, PA, USA
| | - Lauren E Bobby
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Kristen M Gawronski
- School of Pharmacy, Lake Erie College of Osteopathic Medicine, Erie, PA, USA
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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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11
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MacMillan KDL. Neonatal Abstinence Syndrome: Review of Epidemiology, Care Models, and Current Understanding of Outcomes. Clin Perinatol 2019; 46:817-832. [PMID: 31653310 DOI: 10.1016/j.clp.2019.08.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of neonatal abstinence syndrome owing to prenatal opioid exposure has grown rapidly in recent decades and it disproportionately affects rural, non-white, and public insurance-dependent populations. Treatment consists of pharmacologic and nonpharmacologic interventions with wide variability in approaches across the United States. Standardizing clinical assessment, minimizing unnecessary interruptions, and prioritizing nonpharmacologic and family-centered care seems to improve hospital outcomes. Neonatal abstinence syndrome may have long-term developmental and biological effects, but understanding is limited owing in part confounding biosocial factors. Early intervention and longitudinal support of the infant and family promote better outcomes.
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Affiliation(s)
- Kathryn Dee Lizcano MacMillan
- Division of Neonatology and Newborn Medicine, Massachusetts General Hospital for Children, Good Samaritan Medical Center, 55 Fruit Street, Founders 5-530, Boston, MA 02114, USA; Division of Pediatric Hospital Medicine, Massachusetts General Hospital for Children, Good Samaritan Medical Center, 55 Fruit Street, Founders 5-530, Boston, MA 02114, USA.
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12
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Comparative effectiveness of opioid replacement agents for neonatal opioid withdrawal syndrome: a systematic review and meta-analysis. J Perinatol 2019; 39:1535-1545. [PMID: 31316147 PMCID: PMC7784556 DOI: 10.1038/s41372-019-0437-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 05/22/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE(S) To compare short-term treatment outcomes of opioid pharmacotherapy for neonatal opioid withdrawal syndrome (NOWS). STUDY DESIGN PubMed/MEDLINE, Embase, PsycINFO, and The Cochrane Library were searched from inception through September 30, 2018. Primary outcome was treatment duration (LOT). Secondary outcomes included hospitalization duration (LOS) and rate of adjunct drug needed (RAD). RESULTS Of 753 publications, 11 studies met inclusion criteria. There was no difference in LOT (WMD -1.39 [-5.79 to -3.01] days, I2 82%) or LOS (WMD -1.48 [-5.75 to -2.79] days, I2 92%) between morphine and methadone. RAD with morphine was higher (RR 1.51 [1.35-1.69], I2 0%). Buprenorphine was associated with shorter LOT (WMD 7.70 [0.88-14.53] days, I2 76%) and LOS (WMD 5.61 [-0.01 to -11.24] days, I2 60%) compared with morphine, in addition to methadone according to two cohort studies. CONCLUSIONS Methadone had superior primary treatment success compared with morphine. Buprenorphine was associated with the shortest overall durations of treatment and hospitalization.
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13
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Whalen BL, Holmes AV, Blythe S. Models of care for neonatal abstinence syndrome: What works? Semin Fetal Neonatal Med 2019; 24:121-132. [PMID: 30926259 DOI: 10.1016/j.siny.2019.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Opioid use disorders and the prescription of long-acting medications for their treatment have increased dramatically over the last decade among pregnant women. Newborns who experience prolonged in utero opioid exposure may develop neonatal abstinence syndrome (NAS). Until recently, much of the focus on improving care for NAS has been on pharmacologically-based care models. Recent studies have illustrated the benefits of rooming-in and parental presence on NAS outcomes. Single center Quality Improvement (QI) initiatives demonstrate the benefits of non-pharmacologic care bundles and symptom prioritization in decreasing the proportion of infants pharmacologically treated and length of hospital stay. Little remains known about the impact of these varied cared models on maternal-infant attachment and mental health. In this review article, we will propose an optimal model of care to improve short- and long-term outcomes for newborns, their mothers and families, and perinatal care systems.
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Affiliation(s)
- Bonny L Whalen
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, DHMC Pediatrics, One Medical Center Dr., Lebanon, NH, 03756, USA.
| | - Alison V Holmes
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, The Dartmouth Institute, DHMC Pediatrics, One Medical Center Dr, Lebanon, NH, 03756, USA.
| | - Stacy Blythe
- School of Nursing and Midwifery, Western Sydney University, Translational Health Research Institute (THRI), Locked Bag 1797, Western Sydney University, Penrith, NSW, 2751, Australia.
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Pregnant women with opioid use disorder and their infants in three state Medicaid programs in 2013-2016. Drug Alcohol Depend 2019; 195:156-163. [PMID: 30677745 DOI: 10.1016/j.drugalcdep.2018.12.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Maternal opioid use disorder (OUD) has serious consequences for maternal and infant health. Analysis of Medicaid enrollee data is critical, since Medicaid bears a disproportionate share of costs. METHODS This study analyzes linked maternal and infant Medicaid claims data and infant birth records in three states in the year before and after a delivery in 2014-2015 (2013-2016) examining health, health care use, treatment, and neonatal outcomes. Diagnosis and procedure codes identify OUD and other substance use disorders (SUDs). RESULTS In the year before and after delivery, 2.2 percent of the sample had an OUD diagnosis, and 5.9 percent had a SUD diagnosis other than OUD. Of the women with OUD, 72.8% had treatment for a SUD in the year before and after delivery, but most had none in an average enrolled month, and only 8.8% received any methadone treatment in a given month. Pregnant women with OUD had delayed and lower rates of prenatal care compared to women with other substance use disorders (SUDs). Infants of mothers with OUD did not differ from infants of mothers with other SUDs in rate of preterm or low birth weight but had higher NICU admission rates and longer birth hospitalizations. Health care costs for women with an OUD were higher than those with other SUDs. CONCLUSIONS There is an urgent need for comprehensive, evidence-based OUD treatment integrated with maternity care. To fill critical gaps in care, workforce and infrastructure innovations can facilitate delivery of preventive and treatment services coordinated across settings.
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Gullickson C, Kuhle S, Campbell-Yeo M. Comparison of outcomes between morphine and concomitant morphine and clonidine treatments for neonatal abstinence syndrome. Acta Paediatr 2019; 108:271-274. [PMID: 29972601 DOI: 10.1111/apa.14491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 06/29/2018] [Accepted: 07/03/2018] [Indexed: 11/30/2022]
Abstract
AIM To examine whether adding clonidine to the morphine regimen for treatment of neonatal abstinence syndrome (NAS) is associated with a shorter length of treatment compared with morphine alone. METHODS Using a retrospective cohort design, infants with NAS resulting from opioid exposure delivered between 2006 and 2015 (n = 174) were identified using the Nova Scotia Atlee Perinatal Database (NSAPD). Maternal and infant characteristics were collected from the NSAPD. The database was augmented with chart review for treatment information. RESULTS The incidence of NAS in the study population increased fivefold from 1.48/1000 live births in 2007 to 7.50/1000 live births in 2015. Of the 174 infants, 22 were treated with morphine and 100 were treated with morphine + clonidine. Longer length of treatment (p = 0.004) and higher peak morphine dose (p = 0.045) were observed in the combination group. CONCLUSION The increase in the incidence of NAS is consistent with recent published reports. The increase in length of treatment and peak morphine dose in the morphine + clonidine group is in marked contrast to previous work on this treatment combination. Further study on the impact of clinical characteristics such as methadone and antidepressant exposure on the association is warranted.
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Affiliation(s)
| | - Stefan Kuhle
- Department of Pediatrics; Dalhousie University; Halifax NS Canada
- Department of Obstetrics and Gynaecology; Dalhousie University; Halifax NS Canada
| | - Marsha Campbell-Yeo
- Department of Pediatrics; Dalhousie University; Halifax NS Canada
- School of Nursing; Faculty of Health Professions; Dalhousie University; Halifax NS Canada
- Centre for Pediatric Pain Research; IWK Health Centre; Halifax NS Canada
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Management of Neonatal Abstinence Syndrome: The Importance of a Multifaceted Program Spanning Inpatient and Outpatient Care. Jt Comm J Qual Patient Saf 2018; 44:309-311. [DOI: 10.1016/j.jcjq.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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17
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Haycraft AL. Pregnancy and the Opioid Epidemic. J Psychosoc Nurs Ment Health Serv 2018; 56:19-23. [PMID: 29505087 DOI: 10.3928/02793695-20180219-03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/24/2018] [Indexed: 11/20/2022]
Abstract
Opioid use disorder (OUD) in pregnancy is increasing, which often results in poor maternal and neonatal outcomes including neonatal abstinence syndrome (NAS) as a result of lack of prenatal care and inadequate substance use disorder management. Practice guidelines have been developed to manage OUD during and after pregnancy for mother and baby, but barriers exist, limiting comprehensive implementation. To reduce the impact of OUD in pregnancy and associated maternal and neonatal sequela, implementing compassionate evidence-based care and a non-punitive response is needed. A stigma-free approach, substance use disorder screening, medication-assisted treatment, screening and treatment of mental health disorders, and an after-birth environment that promotes maternal-child bonding are recommended. [Journal of Psychosocial Nursing and Mental Health Services, 56(3), 19-23.].
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Devlin LA, Lau T, Radmacher PG. Decreasing Total Medication Exposure and Length of Stay While Completing Withdrawal for Neonatal Abstinence Syndrome during the Neonatal Hospital Stay. Front Pediatr 2017; 5:216. [PMID: 29067285 PMCID: PMC5641300 DOI: 10.3389/fped.2017.00216] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/25/2017] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Neonatal abstinence syndrome (NAS) is a rapidly growing public health concern that has considerably increased health-care utilization and health-care costs. In an effort to curtail costs, attempts have been made to complete withdrawal as an outpatient. Outpatient therapy has been shown to prolong exposure to medications, which may negatively impact neurodevelopmental and behavioral outcomes. We hypothesized that the implementation of a modified NAS protocol would decrease total drug exposure and length of stay while allowing for complete acute drug withdrawal during the neonatal hospital stay. METHODS Data were derived retrospectively from medical records of term (≥37 0/7) infants with NAS who were treated with pharmacologic therapy in the University of Louisville Hospital Neonatal Intensive Care Unit from 2005 to 2015. The pharmacologic protocol (SP1) for infants treated between 2005 and March 2014 (n = 146) dosed oral morphine every 4 h and utilized phenobarbital as adjuvant therapy. Protocol 2 (SP2) initiated after March 2014 (n = 44) dosed morphine every 3 h and used clonidine as adjuvant therapy. Charts were reviewed for demographic information and maternal drug history. Maternal and infant toxicology screens were recorded. The length of morphine therapy and need for adjuvant drug therapy were noted. Length of stay was derived from admission and discharge dates. RESULTS The length of morphine therapy was decreased by 8.5 days from 35 to 26.5 days (95% CI 4.5-12 days) for infants treated with SP2 vs. SP1 (p < 0.001). The need for adjuvant pharmacologic therapy was decreased by 24% in patients treated with SP2 vs. SP1 (p = 0.004). The length of stay was decreased by 9 days from 42 to 33 days (95% CI 5.1-13 days) for infants treated with SP2 vs. SP1 (p < 0.001). The decreased length of stay resulted in an average reduction of hospital charges by $27,090 per patient in adjusted 2015 US Dollars. CONCLUSION This study demonstrates that total drug exposure and length of stay can be reduced while successfully completing acute withdrawal during the neonatal hospital stay.
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Affiliation(s)
- Lori A Devlin
- Division of Neonatal Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, United States
| | - Timothy Lau
- Department of Educational and Counseling Psychology, University of Louisville, Louisville, KY, United States
| | - Paula G Radmacher
- Division of Neonatal Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, United States
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