Opioid Dependence in Infants: A Growing Crisis

IT IS ESTIMATED one baby is born every hour in the United States with a dependence on opiate drugs. This heartbreaking epidemic is complex and not easy to treat. Because the birthing process brings an abrupt cessation of the opioid, these tiny addicts immediately go into withdrawal. Symptoms may include crying for hours due to pain and discomfort as their bodies adjust. Not surprisingly, they often are fussy and difficult to calm. The official diagnosis of infant drug withdrawal is neonatal abstinence syndrome (NAS), and sadly, the health impact on these children can be significant and lifelong. “There are studies that show an increased risk of congenital heart defects in babies exposed to codeine in the first trimester, but in general, the chronic use of opioids in pregnancy increases the risk for fetal growth restriction, placental abruption (the separation of the placenta from the uterine wall), preterm delivery and fetal death,” said James J. Steigerwald, MD, a member of the OB Hospitalist Group at Memorial Hospital in Colorado Springs, Colo.¹

NAS was first formally described in the 1970s by Philadelphia pediatrician Loretta Finnegan, MD, yet all these decades later, it remains a challenging condition to diagnose and report. For one thing, although a woman’s drug use during pregnancy can be confirmed by testing the baby’s urine and first bowel movement, withdrawal exhibits a cluster of symptoms easily mistaken for other maladies. The hallmark symptoms are shrill, inconsolable crying and tremors, but the baby may also suffer muscle spasms, convulsions, vomiting, diarrhea, insomnia, trouble feeding, fever, nasal stuffiness, scratching, yawning and sweating, making a straightforward diagnosis difficult at best. In addition, infants whose mothers also took stimulants such as cocaine or methamphetamines typically don’t display the classic signs of withdrawal from prescription opioids and heroin, complicating diagnosis and treatment. “One of the problems with the diagnosis of NAS is that there is no national or state guidance on when to code it,” said Debra Bogen, MD, a pediatrician and NAS expert at Children’s Hospital of Pittsburgh of UPMC. “It’s a messy term.” Pennsylvania state health official Rachael Levine, MD, agrees: “NAS is a clinical diagnosis. It involves lab testing. But some of the symptoms are nonspecific in terms of a jittery baby. It is not always obvious and can be challenging.”²

Adding to challenges with diagnosis and treatment plans, the sheer number of cases continues to rise, potentially overwhelming hospitals ill-equipped to handle them. According to U.S. News & World Report, the national rate of babies born with NAS increased fivefold from 2000 to 2012. Additionally, 27 in every 1,000 babies were admitted to neonatal intensive care units (NICUs) suffering from NAS in 2013, compared with seven in every 1,000 in 2004, according to a study published in the New England Journal of Medicine.³

An Emphasis on Integrative Care

Opioids include various prescription medications such as Vicodin, Percocet, Norco, Lortab, codeine, oxycodone, hydrocodone and Dilaudid. But, when it comes to opioid dependence in infants, the list also includes nonprescription drugs such as heroin. Sadly, babies born with NAS may also have been exposed to medication-assisted therapy used to treat their mother’s opioid addiction, including drugs like Suboxone or methadone, adding yet another layer of complexity to the growing healthcare crisis. When it comes to treatment, most NAS babies require decreasing doses of morphine or methadone until withdrawal symptoms subside, although some infants have attained sufficient relief with a regimen of cuddling and swaddling.

Dr. Steigerwald notes that despite the hurdles, there are treatment options, although until recently, the choices were extremely limited. “Treatment for the newborn usually consists of giving them opiates and gradually weaning down the dose.”

With escalating caseloads around the country, researchers have been seeking more effective treatment options. Rather than a one-size-fits-all approach, a 2018 study states the effective management of NAS requires a coordinated “cascade of care,” from prevention through long-term follow-up. Researchers who participated in the study identified four essential areas with the potential to improve care for this increasingly common complication of opioid use. “Greater resources, coordination and cross-disciplinary education are urgently needed across the cascade of care to effectively address NAS,” stated Jennifer L. Syvertsen, PhD, MPH, of the University of California, Riverside, and colleagues at the University of Southern California.⁴

In their study, researchers conducted in-depth interviews with 18 central Ohio healthcare providers caring for infants and families affected by NAS. Ohio has among the highest rates of opioid use and NAS in the United States. Informed by analysis of the provider interviews, the researchers listed the following interrelated components for effective treatment:

• Prevention. Care begins with preventing the misuse of opioids and other drugs. Preventive efforts should encompass the “social determinants of health” such as poverty, lack of education and limited opportunities.
• Prenatal care and drug treatment. The study stressed the need for supportive care for pregnant women using opioids rather than punitive approaches. While comprehensive care programs have yielded promising results, NAS can occur even in infants born to mothers receiving recommended medication-assisted treatment for opioid use disorder.
• Labor and delivery. Infants must be monitored for signs of NAS, with treatment if needed; providers stressed that consistency in following protocols is critical to reducing infant length of stay in the hospital. Programs to sensitize staff and mitigate stereotyping attitudes toward mothers of babies with NAS have also led to better care. One challenge identified in rural areas, for example, is that the infant often has to be transported to a NICU, creating barriers to mother-infant bonding.
• Aftercare. Supportive aftercare includes access to drug treatment and social services, monitoring the child’s development and providing a healthy home environment for the infant to thrive. While services are typically available for pregnant women, all too often they shut down after delivery.

“Our current focus on the period of pregnancy alone is insufficient to address the complexity of NAS,” Dr. Syvertsen explained. The study goes on to highlight the need for programs and policy at each stage of treatment, toward the critical goal of stemming the tide of NAS. “Unless we make a serious political commitment to create fair drug policy, adapt a more integrative approach to addressing NAS and adequately support the initiatives that we know can work, NAS incidence will continue to rise and devastate communities.”

Blaming and Shaming: Addressing the Stigma

Historically, a significant impediment to better care for babies with NAS has been the tendency to blame their mothers for using illegal substances while pregnant. Stephen Patrick, MD, MPH, MS, a neonatologist at Monroe Carell Jr. Children’s Hospital at Vanderbilt University, says among people with substance use disorders, “there’s no population that’s more stigmatized than pregnant women,” adding there is a sense of “How could you do this to your baby?”⁵

Hendrée Jones, PhD, executive director of the University of North Carolina Horizons Program, which offers mothers with substance use disorders intensive treatment, psychiatry, case management, therapy and other services, agrees. “There is a tremendous amount of blaming and shaming and stigma,” she says. “Unfortunately, that is something that has not changed at all in the 25 years I’ve been in the field.” Tragically, this stigma and the resulting shame drive a woman from the very treatment that could help her and her unborn child.

Now the medical director at Wellbridge Addiction Treatment and Research in New York, Harshal Kirane, MD, had previously worked and done research at the epicenter of what may be one of the worst areas of opioid addiction in Staten Island, N.Y. He recently led an assessment that evaluated the attitudes of physicians from all fields across the Northwell Health System. The survey assessed clinician attitudes and practices in treating opioid dependence, and the data directly influenced an expanded framework now being used to address treatment at the hospital level. “There remains inadequate physician training in addressing pain management, and that’s certainly true in obstetrics and gynecology, which means substance abuse issues are often not screened for or addressed in preventative ways,” he explains. “Once someone is pregnant with an opioid addiction, the situation rapidly deteriorates each day treatment is delayed. A woman struggling with this disorder feels stigmatized, is afraid, and in the process of avoiding care for her addiction, is also not accessing basic care for her pregnancy. By the time of delivery, the situation is much more dire than if these issues had been addressed way upstream.”

Recognizing the scope of the problem, a multidisciplinary team spearheaded by Salem Magarian, MD, at East Cliff Family Health Center in Santa Cruz, Calif., has developed a care model worth a second look. This comprehensive treatment approach involves a network of agencies throughout the county. The result is an innovative, voluntary prenatal program in which every pregnant woman can access home visits and drug and alcohol counseling without facing judgment or fear of repercussion. In a typical scenario, a social worker gets to know mothers before they deliver and helps support them while their babies are in the NICU. Nurses are trained to provide comfort care to babies going through withdrawal, keep them in quiet rooms and teach their mothers how to swaddle them with skin-to-skin contact. In addition, the team developed a weaning protocol. Every baby who exhibited signs of serious withdrawal was put on the same small dose of morphine, which increased up to a certain limit until the baby stabilized. Babies who were stable for 48 hours were sent home to wean.

While there hasn’t yet been a peer-reviewed investigation into the model developed in Santa Cruz, the limited data thus far seems to support the approach. Nationally, babies with NAS tend to stay in the hospital an average of 3.5 times longer than other newborns. Under this program, stays for impacted infants in the NICU dropped from 14 days to nine. In addition fewer babies returned to the emergency room while more of the mothers remained in long-term recovery.⁵

In another notable treatment model at Yale New Haven Children’s Hospital, under the guidance of Matthew Grossman, MD, doctors implemented the “eat/sleep/console” system, in which they put babies who had been exposed to opioids in utero in low-stimulation rooms with their parents sleeping in the hospital. Babies were comforted frequently, but only given morphine on select occasions. According to a study published in the journal Pediatrics last year, the percentage of infants being treated with morphine dropped from 98 percent to 14 percent, and the average stay decreased from 22 days to six.⁵

“I absolutely see these programs having tremendous merit,” say Dr. Kirane. “The emphasis of addiction treatment in pregnancy has to move toward a more humanistic, interdisciplinary approach to care. When an entire team can be mobilized to support a new mother in this delicate and vulnerable time, it seems to be a really powerful opportunity to meet a very complex need.”

Hope on the Horizon

As various stakeholders seek alternatives to traditional opioid treatment for newborns, there are many emotional, ethical and legal considerations. Questions include whether criminal penalties should be lessened or eliminated for women whose infants are exposed to opioids, or whether policymakers should destigmatize substance use disorder for pregnant women and treat it as a chronic medical condition instead. The latter would allow those who are suffering from opioid addiction to receive behavioral therapy and medication-assisted treatment, also known as a wholepatient approach.

“As far as the management of NAS, it has remained an area of limited innovation beyond engaging mothers in opioid replacement therapies during pregnancy,” adds Dr. Kirane. “Even with these treatments, the infant will still present with NAS; however, in contrast to infants born to mothers who never engaged in any type of treatment during pregnancy, the severity and other health consequences of NAS is much more problematic than when it’s unfolding in an anticipated and controlled manner.”