How the opioid crisis affects the next generation

Neonatal abstinence syndrome (NAS), a series of health issues that arises in a newborn when their mother abused opioids while they were in the womb, rose fivefold in the US from 2000 to 2012. And in 2012 alone, one infant was born with NAS every 25 minutes. It's no surprise that it’s largely due to America’s current opioid crisis.

Drugs that are abused during pregnancy, which can include heroin, the synthetic opioid fentanyl, and prescription pain relievers like codeine, oxycodone, methadone and others, pass to the baby through the placenta, the organ that provides oxygen and nutrients to a developing fetus. The baby can actually become addicted to whatever drug their mother was taking.

Expectant mothers who use these types of drugs up until delivery increase the risk of dependency in their child at birth. “After delivery, the baby is basically deprived of the opiates that he or she had been receiving in utero,” says Bill Trawick, NP, of Alaska Regional Hospital in Anchorage, Alaska, who specializes in neonatal-perinatal medicine. Since the baby is not receiving the drug, withdrawal symptoms are likely as the drug clears out of their system. These can include nursing and feeding issues, digestive problems and even more serious conditions like seizures.

Exposure to drugs during pregnancy is a serious problem, one that all hopeful parents and pregnant couples should be aware of. Here are some important things to know, including the types of complications that arise for newborns with NAS, how much the syndrome affects the cost of having a child, what doctors and hospitals can do to help and how to pursue alternatives to drugs when pregnant.

When a child has NAS, symptoms present themselves about one to three days after delivery, sometimes longer. Typically, NAS babies are monitored in the hospital for at least four to five days after birth so doctors can observe them as symptoms begin. Symptoms can vary depending upon how long the mother used the drug and the type of drug she was on.

Signs include:

• High-pitched crying and irritability
• Trouble feeding
• Gastrointestinal issues like vomiting or loose stools
• Autonomic dysfunction, like sweating, sneezing, fever or yawning
• Failure to thrive
• Skin irritation issues like diaper rash

More serious complications can include seizures, low birth weight and respiratory issues.

And in addition to NAS, babies who are exposed to drugs or alcohol during pregnancy have an increased risk of serious health complications like sudden infant death syndrome (SIDS), premature birth and developmental problems.

Before a child is discharged from the hospital, a pediatric follow-up appointment should be discussed and scheduled so the child receives the proper check-up.

If a child has had prenatal opioid exposure, a NAS diagnosis is expected. A diagnosis can also be confirmed if a maternal or infant urine toxicology screening shows positive levels of opioids or other substances.

However, even though these newborn specimen screenings can help determine a NAS diagnosis, it is possible they may fail to pick up on prenatal drug exposures. Also, certain symptoms of NAS in newborns, like seizures and irritability, may indicate other serious conditions like hypoglycemia, hypocalcemia, and polycythemia rather than NAS, so those should also be ruled out with blood count, serum glucose and calcium testing.

A mother’s medical history, specifically opioid use history, and the appearance of withdrawal symptoms after birth are the most effective ways of confirming a NAS diagnosis, says Trawick.

He adds, that there are some other complications associated with a NAS diagnosis, too. Many women who are addicted to drugs are not thinking clearly. “When a mother is so ill from her addiction, she does not allow her brain to recognize that she is the source of this harm,” says Trawick. There can be a stigma when it comes to speaking of drug use, and it can often be difficult for patients and pediatricians or OBGYNs to discuss, resulting in a delayed diagnosis.

One study, published in the journal Addiction, estimated that the total cost for hospital care for all NAS cases in the US was $316 million in 2012. Families who have an infant with NAS can expect a longer hospital stay as well—sometimes 3.5 times longer than babies without NAS, tripling costs and bringing hospital care costs to almost $17,000, up from a typical stay of $5,610.

When it comes to overall healthcare costs, a Vanderbilt University study published in the Journal of Perinatology, shows that in 2012, national healthcare charges for treating NAS totaled $1.5 billion, up from $731 million in 2009.

Treatments for NAS can vary from infant to infant, depending upon the type of drugs the mother took, how healthy the infant was at birth, the child’s abstinence scores and when the baby was born—full-term or premature. Doctors monitor NAS-diagnosed babies in the hospital, observing their symptoms and treating them accordingly. Children who are vomiting or dehydrated may need IV fluids. If they’re showing signs of unusual fussiness, gentle care tips are suggested, such as rocking, minimizing any noise or lights and swaddling.

If symptoms continue to escalate, babies may need medications like methadone or morphine to aid in withdrawal, slowing weening them off the drug as they show signs of improvement. This often results in longer hospital stays beyond the initial monitoring period.

Babies who aren’t growing or have developmental problems may need adjusted feedings. Things like smaller, more frequent portions and high calorie meals can be helpful for growth.

The best thing a mother can do for her unborn child is practice healthy habits.

It’s also important for physicians to be proactive. Doctors are encouraged to perform screenings using questionnaires, and to discuss the seriousness of NAS during preconception counseling and initial pregnancy appointments. “Obstetricians are obligated to discuss substance use during their early prenatal encounters,” says Trawick. “There are a number of interviewing tools that physicians and other providers can use to screen mothers to identify their substance use.”

Two major programs, the CDC’s Treating for Two: Safer Medication Use in Pregnancy initiative and the National Preconception Health and Health Care Initiative, urge physicians to prescribe mindfully and help women of reproductive age practice healthy habits prior to getting pregnant, especially since the CDC reports that 86 percent of women who get pregnant while abusing opioids, didn’t plan to become pregnant. And, the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain recommends:

• Physicians discuss opioid use with any woman of reproductive age, including its effect on a developing fetus, and how those women who are taking opioid drugs can avoid unwanted pregnancies.
• That patients and doctors work together when deciding whether or not opioid medications are necessary for chronic pain while pregnant. And if not, what other non-opioid therapies are available for the chronic pain they are experiencing. If opioids are needed, the lowest effective dose should be prescribed.

In addition to the formal physician plans, there are some other national initiatives aiming to reduce the number of NAS cases, as well. They include:

Warning labels: The Food and Drug Administration requires that all opioid medications have a black box warning that notifies users of the NAS risks associated with long-term opioid use during pregnancy.

Prescription drug monitoring programs (PDMPs): These databases, operating in every state in the United States except Missouri, monitors controlled prescriptions distributed by pharmacies to a patient so their physician can learn about a patient’s prescription history and any medications they’re currently taking before prescribing any more.

Management of opioid use disorder in women: For women with opioid use disorder, the Substance Abuse and Mental Health Services Administration and the American College of Obstetricians and Gynecologists recommends medication-assisted therapy (MAT) with methadone or buprenorphine. These drugs are safe—even for pregnant women—and trick the brain into thinking it’s receiving whatever the abused drug is, without causing withdrawal.

These initiatives, partnered with raising awareness of the risk of opioid use during pregnancy, can lower the risk of NAS. Couples who are ready to start a family should schedule a pre-conception appointment with their doctor. In these meetings, lifestyle habits and current prescription medications can be discussed, as well as treatment and prescription alternatives. And, if addiction counseling is needed, they can assist couples with those options as well.

Pregnant women who are struggling with untreated opioid addiction should inform their doctor right away. But Trawick says the only way we’re going to lower the climbing NAS rates is to bring attention to the syndrome and to treat women before they become pregnant.

“If we're just devoting our attention, dollars and expertise on the baby, we've already lost the battle. We need to focus our attention on substance abuse in pregnant and potentially pregnant women.”