Our Medical Director, Richard Margolis MD, helps us make sense of new information in psychiatry, addiction, and behavioral health. This article summaries a New England Journal of Medicine review of current literature on neonatal abstinence syndrome, including clinical characteristics, prevention, identification, and treatment.
The incidence of the neonatal abstinence syndrome has increased substantially in the past decade.
The increase in cases of the neonatal abstinence syndrome corresponds with the reported rise in opioid use during pregnancy, which is attributed to the more liberal use of prescribed opioids for pain control in pregnant women, illicit use of opioids such as oxycodone and heroin, and a dramatic increase in opioid-substitution programs for the treatment of opioid addiction. The pattern of opioid use has also shifted from an inner-city, low-income population to a more socioeconomically and demographically diverse population that includes pregnant women. The causes of the neonatal abstinence syndrome are similarly diverse, including in utero exposure to prescribed or illicit opioids and to agents used for the treatment of maternal opioid addiction.
Illicit opioid use is often complicated by a chaotic lifestyle that includes drug-supporting and drug-seeking behaviors. This lifestyle may hinder access or commitment to medical and social services, leading to substantial risks of illness and death. These risks can be mitigated with opioid-substitution treatment, which has benefits for both health and social outcomes. Methadone is currently the most commonly prescribed treatment for opioid addiction during pregnancy, although the evidence suggests that buprenorphine may be associated with less severe neonatal withdrawal than methadone.
The neonatal abstinence syndrome refers to a postnatal opioid withdrawal syndrome that can occur in 55 to 94% of newborns whose mothers were addicted to or treated with opioids while pregnant. Other terms have also been used to describe the syndrome, including the neonatal withdrawal syndrome, the neonatal drug withdrawal syndrome, and neonatal withdrawal. Although the neonatal abstinence syndrome is the term used most frequently in the literature, neonatal withdrawal is probably a more accurate description of the syndrome.
The neonatal abstinence syndrome has been described as a complex disorder that primarily involves the central and autonomic nervous systems and the gastrointestinal system. The clinical manifestations of the syndrome vary ranging from mild tremors and irritability to fever, excessive weight loss, and seizures. Clinical signs typically develop within the first few days after birth, although the timing of their onset, as well as their severity, can vary. This variation is poorly understood and is believed to be multi-factorial. In particular, the type of opioid and the dose and timing of exposure may alter the risk of withdrawal. Clinical manifestations may develop later in infants who have been exposed to opioids with a longer half-life (e.g., methadone and buprenorphine) than in infants exposed to short-acting opioids.
Primary-prevention strategies are needed to address the epidemic of opioid use and the associated development of the neonatal abstinence syndrome. Ongoing surveillance is essential to inform public health–related efforts aimed at prevention. Evidence suggests that in the United States, states with the highest rates of prescription opioid use also have the highest rates of the neonatal abstinence syndrome. Therefore, targeted initiatives to address prescribing practices may help to reduce opioid use in women of childbearing age and prevent the subsequent development of the neonatal abstinence syndrome. Efforts are under way to address the over-prescribing of opioids, such as the introduction of programs to monitor opioid-drug prescribing practices, regulation of pain-management clinics, and establishment of opioid dosage thresholds. Health care providers are encouraged to practice safe and judicious prescribing of opioids to women of childbearing age.
The increased incidence of the neonatal abstinence syndrome and soaring increases in associated health care costs warrant a consistent and comprehensive approach to mitigating the negative outcomes for affected infants, their mothers, and the health care system. Recent innovations in management include standardized protocols for treatment, which have positive effects on important outcomes such as the duration of opioid treatment, the length of the hospital stay, and the use of adjunctive drugs. In addition, evidence from pharmacokinetic models supports the development of empirically based dosing protocols. Breast-feeding and rooming-in are promising non-pharmacologic strategies that may also improve outcomes for infants and mothers, including maternal satisfaction with and involvement in the care of the newborn.