Maternal Opiate Use Research Articles

Caring for Pregnant Women Who Use Opioids and Their Feti

Recently, antepartum maternal opiate use (OU) increased from 1.19 to 5.63 per 1,000 hospital births per year. One study showed that 4.7% of pregnant women reported using an illicit substance in the past months. OU in pregnancy has been associated with an increased risk of spontaneous abortion, preeclampsia, miscarriage, stillbirth, low birth weight, and maternal death. In addition, opioid exposure during pregnancy has been linked to neonatal abstinence syndrome (NAS). The outcome is unfavorably influenced by delays in diagnosis or treatment.

41 Fostering Hope: The Comprehensive Accessible care for Infants with Neonatal abstinence (CAIN) Study

Abstract Introduction/Background Neonatal Abstinence Syndrome (NAS) occurs in newborns exposed to drugs in-utero. In Canada, maternal opiate use in pregnancy has been steadily rising resulting in as many as 1850 babies born with NAS per year. Management of babies born with NAS requires supportive, interdisciplinary care. Depending on the severity of NAS, babies may be cared for with non-pharmacological interventions or some may need to be admitted to the Neonatal Intensive Care Unit for extended hospital stays to receive medication and management of ongoing complex health care needs. Hospital and community health care providers have expressed concerns around the continuity of care for these babies in their stay in hospital and their transition to home. Objectives This study examined the experiences of hospital and community-based health care providers and families regarding the management of babies with NAS. The driving force behind our inquiry related to our interest in streamlining care for these babies in highly complex health and social systems. Design/Methods In total, 47 interdisciplinary participants were interviewed over a four-month period with individuals from Women’s and Child Health, Community, and family members. Interviewed transcripts were reviewed over several months and were completed in December 2019 using an inductive thematic analysis which culminated in the identification of an overarching theme linked with primary themes. ​ Results The study identified existing gaps in the management of these patients, determined how to improve communication between hospital and community networks, and provided a better understanding of the attitudes, perceptions and experiences of hospital and community personnel. The overarching theme identified was hope, with the primary themes being: system, mental health, mother/baby, judgement, and knowledge (see Figure 1). Several gaps identified in the system included fear, stigma, and language. Certain solutions proposed for improvement included focused care in a rooming in model for the mother and baby dyad, supporting mothers’ well-being, involving mothers and families, and supporting care providers in a family centered care model. In Figure 1, green lines indicate themes that are linked with and support hope, and red lines indicate themes that are barriers to hope. Conclusion This research demonstrates that programs and interventions implemented when working with mothers and babies with NAS must foster hope in mothers, families, and in the extended care provider team.

Treatment of Neonatal Abstinence Syndrome with Clonidine versus Morphine as Primary Therapy

Background: Maternal opiate use and resulting Neonatal Abstinence Syndrome (NAS) have continued to be a major public health concern in the US. NAS is a result of the abrupt discontinuation of the substances abused or used by the mother during pregnancy. The withdrawal symptoms are seen in about 80% of the neonates exposed to opioids in utero. Pharmacologic treatment is required when the infant fails to respond to supportive care, when scores for withdrawal remain high, if seizures are seen or if withdrawal …

Is There a Difference between those who Require Treatment of Neonatal Abstinence Syndrome

Background: Maternal opiate use, exposure of neonates in utero and Neonatal Abstinence Syndrome (NAS) have continued to be a major public health concern in the US. Neonatal Abstinence Syndrome (NAS) is a result of the abrupt discontinuation of the substances abused or used by the mother during pregnancy. The withdrawal symptoms are seen in about 80% of the neonates exposed to opioids in utero. Pharmacologic treatment is required when the infant fails to respond to supportive care, when scores for …

Association of prenatal opiate exposure with youth outcomes assessed from infancy through adolescence.

This study examined acute findings and long-term outcome trajectories between birth and adolescence in children with prenatal opiate exposure. Ninety children (45 opiate-exposed, 45 non-exposed) completed assessments between 1 month and 15 years of age. Outcome variables (medical, anthropomorphic, developmental, and behavioral) were analyzed at individual time points and using longitudinal statistical modeling. Opiate-exposed infants displayed transient neurologic findings, but no substantial signs or symptoms long term. There were no group differences in growth, cognitive functioning, or behavior at individual time periods; however, the trajectories of outcomes using longitudinal analyses adjusting for variables known to impact outcome demonstrated increased deficits among opiate-exposed children over time with regards to weight, head circumference, cognitive functioning, and behavior. Findings support concerns that maternal opiate use during pregnancy may negatively impact a child's developmental trajectory, which in turn may impose concerns to society (e.g., increased need for social, medical, and/or educational services).

Clinical Decision Support to Improve Dosing Weight Use in Infants with Neonatal Abstinence Syndrome.

Opioid abuse in the United States is a public health emergency. From 2000 to 2009, prenatal maternal opiate use increased from 1.19 to 5.63 per 1,000 births, with up to 80% of in utero opioid-exposed infants requiring pharmacotherapy. This study aimed to increase the percentage of neonatal abstinence syndrome (NAS) medication orders based on birth weight (BW) in neonates admitted to a neonatal intensive care unit with a principal diagnosis of NAS from 29% to 90%, within 4 months of project initiation, and to sustain this for 6 months. This project occurred at an academic medical center with 5,000 deliveries per year and a 49-bed Level III neonatal intensive care unit. We used the Institute for Healthcare Improvement methodology, largely focusing interventions on clinical decision support (CDS) tools. We plotted all measures on Shewhart charts, and Nelson rules differentiated special versus common cause variation. The percent of orders based on BW increased from 29% to 78% after implementing multiple interventions focused primarily on CDS. However, this later decreased to 48% as workarounds began. There was also a significant decrease in the length of stay variability, which persisted throughout the project. CDS is a helpful tool to guide prescribing behavior; however, workarounds can negate its usefulness. Standardized use of BW for weight-based NAS medication prescribing can decrease the length of stay variability. Further studies are needed using a human factors approach to minimize workarounds in CDS and potentially decrease the length of stay in neonates with NAS.

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

Factors associated with the prevalence of neonatal abstinence syndrome in West Virginia.

Neonatal abstinence syndrome (NAS) is a group of problems associated with withdrawal symptoms of a newborn who was exposed to maternal opiate use while in the womb. West Virginia (WV) is of utmost concern as this state exhibits among the highest rates of opioid abuse and consequently, NAS. In this manuscript, we review factors associated with the prevalence of NAS in WV. We provide evidence suggesting that states exhibiting high Medicaid participation demonstrate a high NAS rate, further associating these two factors. Although a similar trend was observed in the substate geographic regions of WV, the presence of regional treatment facilities was negatively associated with NAS prevalence in WV, possibly suggesting that the establishment and utilization of more of these facilities may reduce NAS. Future research investigating factors that contribute to NAS is essential for the elimination of this syndrome.

207: Identifying illicit substance use in pregnancy

5% of pregnant women used illicit substances, 9% consumed alcohol and 15% smoked nicotine cigarettes. A five-fold increase in antepartum maternal opiate use, coincident with the opioid “epidemic” between 2000 and 2009, is also reported. Identification of women who use hazardous substances in pregnancy is a public health priority. However, few screening tools have been evaluated in pregnant women and most were not tested against biochemical assays. The current cross-sectional study sought to compare the performance of 5 substance use screeners in the detection of opiate use in pregnancy. 4 existing screening tools with published evidence regarding detection of drug use in pregnancy (SURP-P, CRAFFT, WIDUS, and 5Ps), plus the NIDA Quick Screen, were administered in counterbalanced order to pregnant women age >18 recruited from 3 major academic hospital sites with diverse prenatal populations. Screeners were followed by self-report collection of past 30-day substance via the Time Line Follow-Back (TLFB), and collection of a urine sample that was tested for opiates. The performance of the screeners was compared to a gold standard that included the urine toxicology and TLFB results. The cohort included 1220 pregnant women: 38% African-American and 15.5% Latina; 35% with a Bachelor’s degree or higher, and 43 (3.5%) self-reported or had a urine test positive for opiates. Assessments were evenly distributed across trimesters. The overall accuracy in identification of a positive urine screen/TLFB for opiates was 84.1% for the NIDA Quick Screen, 72.2% for the WIDUS, 63.2% for the SURP-P, 74.3% for the CRAFFT, and 36.5% for the 5Ps. Sensitivity, specificity, and positive and negative predictive values for the NIDA Quick Screen were 55.8, 85.2, 12.4, and 98.1, respectively. (See Table). The NIDA Quick Screen showed the best comparative accuracy. Performance for most screeners was driven by accurate identification of women who did not use opiates. All screeners but the 5 Ps had poor sensitivity but the 5 Ps had very poor specificity. The positive predictive value for all was poor, suggesting that more work needs to be done to develop screeners. Other ways to improve screening include multi-step screening and use of substance abuse and dependence as outcomes.

A Call for Compassionate Care.

The Substance Abuse and Mental Health Services Administration (2014) reported that 1.1% of pregnant women used nonprescription opiates (either heroin or prescription pills) in the last 30 days. Methadone and buprenorphine are the most common treatments for opiate addiction in pregnant women. Reasons for seeking opiate maintenance treatment (OMT) include keeping custody of one's children and the hope of developing a healthy parenting relationship. Yet, healthcare organizations and professionals have mixed opinions regarding health promotion within the maternal OMT population. Proper education regarding the growing and complex opiate epidemic continues to remain a void for many healthcare professionals. It is imperative that nurses who regularly interact with women in OMT show compassion and competence. It is important to highlight the universality of the challenges and needs of caring for the OMT population. This Perspectives column will explore and describe the context of maternal nonprescription opiate use and the care mothers in OMT should receive based on established nursing ethical standards.

Peripartum Anesthetic Management of the Opioid-tolerant or Buprenorphine/Suboxone-dependent Patient.

Opioid abuse and dependence continues to rise in both the general population and pregnancy, with opioid overdose deaths having quadrupled in the last 15 years. Illicit drug use in last 30 days of pregnancy was over 4% with almost 0.6% documented maternal opiate use at time of birth. The management of the opioid-tolerant, buprenorphine-dependent or methadone-dependent patient in the peripartum period is reviewed. Options for treatment of opioid dependence, acute pain management, and perioperative multimodal analgesia are discussed. The effects of maternal management on neonatal abstinence syndrome are also reviewed.

Changing Trends in the Types of Intrauterine Illicit Drug Exposures in Neonates Admitted to Our Neonatal Intensive Care Unit (NICU)

Background: A variety of illicit drugs abused by women during pregnancy cross the placenta. All of these may be associated with short-term deleterious effects on birth outcomes that are often drug specific. For instance, maternal cocaine use may result in catastrophic birth outcomes like placental abruption, maternal opiate use in neonatal abstinence syndrome and maternal marijuana use in preterm birth. Prevalence of maternal use of specific drugs has probably shifted over the years in keeping with the popularity or access to these substances in …

Neonatal abstinence syndrome: essentials for the practitioner.

The incidence of neonatal abstinence syndrome (NAS) has increased dramatically during the past 15 years, likely due to an increase in antepartum maternal opiate use. Optimal care of these patients is still controversial because of the available published literature lacking sufficient sample size, placebo control, and comparative pharmacologic trials. Primary treatment for NAS consists of opioid replacement therapy with either morphine or methadone. Paregoric and tincture of opium have been abandoned because of relative safety concerns. Buprenorphine is emerging as a treatment option with promising initial experience. Adjunctive agents should be considered for infants failing treatment with opioid monotherapy. Traditionally, phenobarbital has been used as adjunctive therapy; however, results of clonidine as adjunctive therapy for NAS appear to be beneficial. Future directions for research in NAS should include validating a simplified scoring tool, conducting comparative studies, exploring home management options, and optimizing management through pharmacogenomics.

Neonatal Abstinence Syndrome and Associated Health Care Expenditures

Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome primarily caused by maternal opiate use. No national estimates are available for the incidence of maternal opiate use at the time of delivery or NAS. To determine the national incidence of NAS and antepartum maternal opiate use and to characterize trends in national health care expenditures associated with NAS between 2000 and 2009. A retrospective, serial, cross-sectional analysis of a nationally representative sample of newborns with NAS. The Kids' Inpatient Database (KID) was used to identify newborns with NAS by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The Nationwide Inpatient Sample (NIS) was used to identify mothers using diagnosis related groups for vaginal and cesarean deliveries. Clinical conditions were identified using ICD-9-CM diagnosis codes. NAS and maternal opiate use were described as an annual frequency per 1000 hospital births. Missing hospital charges (<5% of cases) were estimated using multiple imputation. Trends in health care utilization outcomes over time were evaluated using variance-weighted regression. All hospital charges were adjusted for inflation to 2009 US dollars. Incidence of NAS and maternal opiate use, and related hospital charges. The separate years (2000, 2003, 2006, and 2009) of national discharge data included 2920 to 9674 unweighted discharges with NAS and 987 to 4563 unweighted discharges for mothers diagnosed with antepartum opiate use, within data sets including 784,191 to 1.1 million discharges for children (KID) and 816,554 to 879,910 discharges for all ages of delivering mothers (NIS). Between 2000 and 2009, the incidence of NAS among newborns increased from 1.20 (95% CI, 1.04-1.37) to 3.39 (95% CI, 3.12-3.67) per 1000 hospital births per year (P for trend < .001). Antepartum maternal opiate use also increased from 1.19 (95% CI, 1.01-1.35) to 5.63 (95% CI, 4.40-6.71) per 1000 hospital births per year (P for trend < .001). In 2009, newborns with NAS were more likely than all other hospital births to have low birthweight (19.1%; SE, 0.5%; vs 7.0%; SE, 0.2%), have respiratory complications (30.9%; SE, 0.7%; vs 8.9%; SE, 0.1%), and be covered by Medicaid (78.1%; SE, 0.8%; vs 45.5%; SE, 0.7%; all P < .001). Mean hospital charges for discharges with NAS increased from $39,400 (95% CI, $33,400-$45,400) in 2000 to $53,400 (95% CI, $49,000-$57,700) in 2009 (P for trend < .001). By 2009, 77.6% of charges for NAS were attributed to state Medicaid programs. Between 2000 and 2009, a substantial increase in the incidence of NAS and maternal opiate use in the United States was observed, as well as hospital charges related to NAS.

The relationship between maternal opiate use, amphetamine use and smoking on fetal growth

Opiate and amphetamine use during pregnancy is frequently associated with cigarette smoking. The negative effects on fetal growth from nicotine combined with opiates or amphetamines during pregnancy are not well documented. To investigate the relationship between maternal opiate or amphetamine use and smoking on fetal growth. A retrospective study was performed comparing pregnancies affected with either opiates or amphetamines with individually matched controls. All mothers smoked cigarettes during pregnancy. The outcome measures included changes in fetal abdominal circumference, head circumference and femur length during the second half of pregnancy and weight, length and head circumference at birth. There were 91 opiate- and 37 amphetamine-affected pregnancies. Deviations from normative data only became apparent from the third trimester. The proportion of infants with a gestation-adjusted birthweight below the 10th percentile was not significantly different in the opiate group compared to their controls 35 (38%). However, there was a significant difference in proportions in the amphetamine group and their controls (P < 0.001). We then compared antenatal growth patterns between the amphetamine group and their controls. Amphetamine-exposed fetuses showed comparable growth parameters in the second trimester but significantly larger head and abdominal circumferences and longer femoral lengths in the third trimester than their respective controls (P < 0.05 for all). When combined with cigarette smoking, opiates had no observed independent effect on birth parameters. Unexpectedly, in the amphetamine group, the negative effects of smoking on growth were altered in late pregnancy.

Maternal Treatment with Opioid Analgesics and Risk for Birth Defects

The effect of medications on a developing fetus is always an important consideration when treating pregnant women in the emergency department. The goal of this large, population-based case-control study was to investigate any associations between maternal opiate use in the first trimester and various birth defects. This study used data from the National Birth Defects Prevention Study for infants born between October 1, 1997 and December 31, 2005. This database includes information on infants born with birth defects of unknown etiology as well as an annual random sample of control infants without birth defects.

Methadone and perinatal outcomes: a retrospective cohort study

The purpose of this study was to examine the relationship among methadone maintenance treatment, perinatal outcomes, and neonatal abstinence syndrome. This was a retrospective cohort study of 61,030 singleton births at a large maternity hospital from 2000-2007. There were 618 (1%) women on methadone at delivery. Methadone-exposed women were more likely to be younger, to book late for antenatal care, and to be smokers. Methadone exposure was associated with an increased risk of very preterm birth <32 weeks of gestation (adjusted odds ratio [aOR], 2.47; 95% confidence interval [CI], 1.40-4.34), being small for gestational age <10th percentile (aOR, 3.27; 95% CI, 2.49-4.28), admission to the neonatal unit (aOR, 9.14; 95% CI, 7.21-11.57), and diagnosis of a major congenital anomaly (aOR, 1.94; 95% CI, 1.10-3.43). There was a dose-response relationship between methadone and neonatal abstinence syndrome. Methadone exposure is associated with an increased risk of adverse perinatal outcomes, even when known adverse sociodemographic factors have been accounted for. Methadone dose at delivery is 1 of the determinants of neonatal abstinence syndrome.

The influence of maternal opiate use in pregnancy on second trimester biochemical markers for Down syndrome

The object of this study is to examine the influence of maternal opiate use on the levels of second trimester biochemical markers for Down syndrome. Maternal opiate use is known to be associated with problems of placental origin and it is possible that the secretion of alpha-feto protein (AFP), free-beta human chorionic gonadotrophin (HCG) and unconjugated oestriol (UE) differs from that of a normal population. Seventy nine women who used opiates in pregnancy were compared to a control group of seventy nine women who did not use opiates and their adjusted marker levels analysed. The adjusted median MoM in the opiate and control groups respectively were: AFP (1.00 vs 0.94), HCG (0.95 vs 1.04) and UE (0.96 vs 1.02), with no significant difference between these groups. This study suggests that the current practice of calculating the risk of Down syndrome from second trimester biochemistry in women using opiate can be performed using data derived from a normal population.

Sudden infant death syndrome in infants born to HIV-infected and opiate-using mothers

Objective: This study was undertaken to determine the role of opiate use during pregnancy as a predisposing factor for sudden infant death syndrome (SIDS) in infants born to HIV-infected mothers....

Opioids in the parturient with chronic nonmalignant pain: A retrospective review

The purpose of this research was to determine the neonatal outcomes of women who had been taking medically prescribed opioids throughout their pregnancy. A retrospective case study was done of 15 pregnancies associated with maternal opiate use between January 1, 1999, and September 30, 2002. Two cases were excluded due to coaddiction. Neonatal data were collected including gestational age, head circumference, length, birth weight, Apgar score at one and five minutes, details of resuscitation required, and Neonatal Abstinence Score. There were 13 pregnancies, which resulted in 13 live births; opioids prescribed included oxycodone, codeine, meperidine, fentanyl, dilaudid, morphine, and methadone. There were four babies with one-minute Apgar score = -5, and two babies with five-minute Apgar score = 5. It was concluded that neonatal growth markers in this population were within normal limits as plotted on the standard growth and development record of Gairdner-Pearson. Five out of 13 (38.5 percent) neonates were diagnosed with opioid discontinuation syndrome.