Davida M. Schiff

Caring for Pregnant Women with Opioid Use Disorder in the USA: Expanding and Improving Treatment.

Purpose of the ReviewOpioid use disorder in the USA is rising at an alarming rate, particularly among women of childbearing age. Pregnant women with opioid use disorder face numerous barriers to care, including limited access to treatment, stigma, and fear of legal consequences. This review of opioid use disorder in pregnancy is designed to assist health care providers caring for pregnant and postpartum women with the goal of expanding evidence-based treatment practices for this vulnerable population.Recent FindingsWe review current literature on opioid use disorder among US women, existing legislation surrounding substance use in pregnancy, and available treatment options for pregnant women with opioid use disorder. Opioid agonist treatment (OAT) remains the standard of care for treating opioid use disorder in pregnancy. Medically assisted opioid withdrawal (“detoxification”) is not recommended in pregnancy and is associated with high maternal relapse rates. Extended release naltrexone may confer benefit for carefully selected patients. Histories of trauma and mental health disorders are prevalent in this population; and best practice recommendations incorporate gender-specific, trauma-informed, mental health services. Breastfeeding with OAT is safe and beneficial for the mother-infant dyad.SummaryFurther research investigating options of OAT and the efficacy of opioid antagonists in pregnancy is needed. The US health care system can adapt to provide quality care for these mother-infant dyads by expanding comprehensive treatment services and improving access to care.

Impact of Parental Presence at Infants’ Bedside on Neonatal Abstinence Syndrome

BACKGROUNDnDespite increased incidence of neonatal abstinence syndrome (NAS) over the past decade, minimal data exist on benefits of parental presence at the bedside on NAS outcomes.nnnOBJECTIVEnTo examine the association between rates of parental presence and NAS outcomes.nnnMETHODSnThis was a retrospective, single-center cohort study of infants treated pharmacologically for NAS using a rooming-in model of care. Parental presence was documented every 4 hours with nursing cares. We obtained demographic data for mothers and infants and assessed covariates confounding NAS severity and time spent at the bedside. Outcomes included length of stay (LOS) at the hospital, extent of pharmacotherapy, and mean Finnegan withdrawal score. Multiple linear regression modeling assessed the association of parental presence with outcomes.nnnRESULTSnFor the 86 mother-infant dyads, the mean parental presence during scoring was on average 54.4% (95% confidence interval [CI], 48.8%-60.7%) of the infants hospitalization. Maximum (100%) parental presence was associated with a 9 day shorter LOS (r = -0.31; 95% CI, -0.48 to -0.10; P < .01), 8 fewer days of infant opioid therapy (r = -0.34; 95% CI, -0.52 to -0.15; P < .001), and 1 point lower mean Finnegan score (r = -0.35; 95% CI, -0.52 to -0.15; P < .01). After adjusting for breastfeeding, parental presence remained significantly associated with reduced NAS score and opioid treatment days.nnnCONCLUSIONSnMore parental time spent at the infants bedside was associated with decreased NAS severity. This has important implications for clinical practice guidelines for NAS.

A Public Health Response to Opioid Use in Pregnancy

The use of opioids during pregnancy has grown rapidly in the past decade. As opioid use during pregnancy increased, so did complications from their use, including neonatal abstinence syndrome. Several state governments responded to this increase by prosecuting and incarcerating pregnant women with substance use disorders; however, this approach has no proven benefits for maternal or infant health and may lead to avoidance of prenatal care and a decreased willingness to engage in substance use disorder treatment programs. A public health response, rather than a punitive approach to the opioid epidemic and substance use during pregnancy, is critical, including the following: a focus on preventing unintended pregnancies and improving access to contraception; universal screening for alcohol and other drug use in women of childbearing age; knowledge and informed consent of maternal drug testing and reporting practices; improved access to comprehensive obstetric care, including opioid-replacement therapy; gender-specific substance use treatment programs; and improved funding for social services and child welfare systems. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool (December 2016).

Neonatal Abstinence Syndrome: Advances in Diagnosis and Treatment.

Importance Neonatal abstinence syndrome, which occurs as a result of in utero opioid exposure, affects between 6.0 and 20 newborns per 1000 live US births. There is substantial variability in how neonatal abstinence syndrome is diagnosed and managed. Objective To summarize key studies examining the diagnosis and management (both pharmacologic and nonpharmacologic) of neonatal abstinence syndrome published during the past 10 years. Evidence Review PubMed, Web of Science, and CINAHL were searched for articles published between July 1, 2007, and December 31, 2017. Abstracts were screened and included in the review if they pertained to neonatal abstinence syndrome diagnosis or management and were judged by the authors to be clinical trials, cohort studies, or case series. Findings A total of 53 articles were included in the review, including 9 randomized clinical trials, 35 cohort studies, 1 cross-sectional study, and 8 case series—representing a total of 11 905 unique opioid-exposed mother-infant dyads. Thirteen studies were identified that evaluated established or novel neonatal abstinence syndrome assessment methods, such as brief neonatal abstinence syndrome assessment scales or novel objective physiologic measures to predict withdrawal. None of the new techniques that measure infant physiologic parameters are routinely used in clinical practice. The most substantial number of studies of neonatal abstinence syndrome management pertain to nonpharmacologic care—specifically, interventions that promote breastfeeding or encourage parents to room-in with their newborns. Although these nonpharmacologic interventions appear to decrease the need for pharmacologic treatment and result in shorter hospitalizations, the interventions are heterogeneous and there are no high-quality clinical trials to support them. Regarding pharmacologic interventions, only 5 randomized clinical trials with prespecified sample size calculations (4 infant, 1 maternal treatment) have been published. Each of these trials was small (fromu200926 to 131 participants) and tested different therapies, limiting the extent to which results can be aggregated. There is insufficient evidence to support an association between any diagnostic or treatment approach and differential neurodevelopmental outcomes among infants with neonatal abstinence syndrome. Conclusions and Relevance Evidence pertaining to the optimal diagnosis and treatment strategies for neonatal abstinence syndrome is based on small or low-quality studies that focus on intermediate outcomes, such as need for pharmacologic treatment or length of hospital stay. Clinical trials are needed to evaluate health and neurodevelopmental outcomes associated with objective diagnostic approaches as well as pharmacologic and nonpharmacologic treatment modalities.

A Police-Led Addiction Treatment Referral Program in Massachusetts

During the first year of a nonjudgmental referral program for drug detoxification and rehabilitation managed by the police department in Gloucester, Massachusetts, 376 persons presented for assistance; 85% had insurance, and the rate of direct placement was 94%.

Bringing attention to a need for a standardized treatment and weaning protocol for neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) due to in-utero opioid exposure has increased 5-fold in the U.S. since 2000, with an incidence of 5.8 per 1,000 live births. NAS now accounts for 3% of all admissions to neonatal intensive care units (NICUs), with associated NICU hospitalization costs of approximately

A police-led addiction treatment referral program in Gloucester, MA: Implementation and participants' experiences

53,000 per infant. Fifty percent to 80% of opioid-exposed infants require extensive pharmacologic treatment for withdrawal symptoms with an average length of hospitalization of three weeks, with a large range from one week to over a month. This variability is due to a variety of maternal-infant factors such as methadone versus buprenorphine exposure, infant feeding method, ability to room-in with the infant, genetic factors, and co-exposures to nicotine, illicit drugs, and psychiatric medications.

Quality improvement initiative to improve inpatient outcomes for Neonatal Abstinence Syndrome

BACKGROUNDnThe increasing rates of opioid use disorder and resulting overdose deaths are a public health emergency, yet only a fraction of individuals in need receive treatment.nnnOBJECTIVEnTo describe the implementation of and participants experiences with a novel police-led addiction treatment referral program.nnnMETHODSnFollow-up telephone calls to participants in the Gloucester Police Departments Angel Program from June 2015-May 2016. Open-ended survey questionnaires assessed experiences of program participants and their close contacts, confirmed police-reported placement, and queried self-reported substance use and treatment outcomes.nnnRESULTSnSurveys were completed by 198 of 367 individuals (54% response rate) who participated 214 times. Reasons for participation included: the program was a highly-visible entry point to the treatment system, belief that placement would be obtained, poor prior treatment system experiences, and external pressure to seek treatment. Most participants reported positive experiences citing the welcoming, non-judgmental services. In 75% (160/214) of the encounters, entry into referral placement was confirmed. Participants expressed frustration when they did not meet program entry requirements and had difficulty finding sustained treatment following initial program placement. At a mean follow-up time of 6.7months, 37% of participants reported abstinence since participation, with no differences between participants who entered referral placement versus those who did not.nnnCONCLUSIONSnA police-led referral program was feasible to implement and acceptable to participants. The program was effective in finding initial access to treatment, primarily through short-term detoxification services. However, the program was not able to overcome a fragmented treatment system focused on acute episodic care which remains a barrier to long-term recovery.

Impact of psychiatric medication co-exposure on Neonatal Abstinence Syndrome severity

ObjectivesTo improve Neonatal Abstinence Syndrome (NAS) inpatient outcomes through a comprehensive quality improvement (QI) program.DesignInclusion criteria were opioid-exposed infants ≥36 weeks. QI methodology including stakeholder interviews and plan-do-study-act (PDSA) cycles were utilized. We compared pre- and post-intervention NAS outcomes after a QI initiative that included: A non-pharmacologic care bundle, function-based assessments consisting of symptom prioritization and then the “Eat, Sleep, Console” (ESC) Tool; and a switch to methadone for pharmacologic treatment.ResultsPharmacologic treatment decreased from 87.1 to 40.0%; adjunctive agent use from 33.6 to 2.4%; hospitalization length from a mean 17.4 to 11.3 days, and opioid treatment days from 16.2 to 12.7 (pu2009<u20090.001 for all). Total hospital charges decreased from

Trainees' knowledge, attitudes, and practices towards caring for the substance-exposed mother-infant dyad

31,825 to