The first study of national rates of neonatal abstinence syndrome (NAS) connected to maternal use of prescription opioids published in the Journal of the American Medical Association on May 1 resulted in a barrage of newspaper articles decrying the rise of “addicted babies,” despite the fact that it is impossible for babies to be “addicted” and with little mention of an accompanying editorial calling for pregnant mothers with opioid addiction to be given the option for methadone treatment as soon as possible.
The JAMA article played into the current climate in many states focusing on law enforcement instead of treatment solutions to prescription drug abuse, with task forces like those in Florida heavily weighted with prosecutors (see article, page tk).
Babies born to mothers who are dependent on opioids, including prescribed painkillers, or methadone or buprenorphine prescribed for opioid addiction, are born with neonatal abstinence syndrome, the correct diagnosis for the condition. They are not “addicted”; they are “dependent,” physicians told ADAW.
The JAMA study
The study, conducted by Stephen W. Patrick, M.D., M.P.H., of the University of Michigan Health System and colleagues, found that the annual rate of maternal opioid use increased almost five times between 2000 and 2009, and the diagnosis of NAS increased almost three times in the same period. NAS can be characterized by irritability, heightened muscle tone, tremors, feeding intolerance, seizures and respiratory distress. This study was the first to estimate the national incidence of NAS in the context of opioid use during pregnancy.
Compared with other hospital births, newborns with NAS were more likely to be covered by Medicaid (78.1 percent). Average hospital charges for newborns diagnosed with NAS increased from $39,400 in 2000 to $53,400 in 2009, but the average length of stay (16 days) was level.
Total hospital charges for NAS increased from $190 million to $720 million, the authors found, and the estimated number of newborns with NAS born in 2009 was 13,539. The authors called for “increased public health measures to reduce antenatal exposure to opiates.” And states have the greatest incentives since they are paying for the majority of hospital expenditures for NAS, the authors conclude.
The accompanying editorial, by Marie J. Hayes, Ph.D., of the University of Maine, and Mark S. Brown, M.D., of Eastern Maine Medical Center, says that NAS research must “establish optimal protocols for maternal opiate dependence with particular focus on methadone treatment induction of the mother early in pregnancy, maternal adherence to treatment, ancillary alcohol use monitoring, and psychiatric care.”
Treatment professionals are concerned that the message — to get pregnant women with opioid addiction into treatment — will be lost, and instead these women will not tell their caregivers they need treatment, or will try to get off of methadone or buprenorphine while pregnant. It is the threat of custody loss — which has already occurred with methadone patients and led to a court case now attracting national attention (see ADAW, March 19, June 6, 2011) — that will drive women away from treatment.
“No support is given to these women,” said Robert G. Newman, M.D., of the International Center for Advancement of Addiction Treatment, who led the fight for methadone treatment decades ago and as former head of Beth Israel Medical Center was in charge of many clinics throughout New York. “What is given is the threat that they may be prosecuted, and the threat that their babies may be taken away from them.”
Newman said it’s “extremely understandable that pregnant women who have a problem with opioids will be unwilling to reveal their situation to their health care provider.” Instead, obstetricians and other health care providers should help the woman find treatment. “But I am not aware of a single prenatal clinic or a single OB practice that says prominently, ‘If you have a problem with opiate dependence, seek treatment, it’s for the benefit of you and your baby.’”
Every physician who provides prenatal care should be required to get a waiver so they can prescribe buprenorphine, Newman told ADAW. “The training takes a few hours in your living room,” he said, referring to the eight-hour online training course. And every physician should be able to refer patients to an OTP for methadone.
Newman said parents should be able to bring a lawsuit against an obstetrician or a prenatal clinic for failing to offer methadone or buprenorphine maintenance to a pregnant woman who is dependent on opioids. “That should be a $10 million lawsuit,” he said. “The malpractice applies to failure to inform patients of an effective treatment if it is available.” Instead, however, physicians may be afraid of being sued because the baby is born “addicted.”
In fact, the highs and lows of short-acting opioids like oxycodone are much more harmful to a baby than the sustained levels provided by long-acting opioids like methadone and buprenorphine, said Stephen Kandall, M.D., a retired neonatologist who was professor of pediatrics at the Albert Einstein College of Medicine in New York City.
“These babies are not addicted; they are physically dependent,” Kandall told ADAW. “Getting off a drug, methadone or buprenorphine that the mother was on, is not difficult,” he said.
Based on work done in a unit in Vancouver, Canada, babies do better with “maternal comfort measures” and breast feeding, said Kandall. The Vancouver unit, run by Ron Abrahams, M.D., has shown that some babies born to women on maintenance opioids don’t need any medication at all, said Kandall, who is the author of Substance and Shadow: Women and Addiction in the United States.
Typically, the treatment is by oral morphine given orally, in decreasing amounts until the baby is weaned comfortably, said Kandall. The babies do have to be observed — they can’t go home right away, he said. Using the Finnegan score (named after Loretta Finnegan, M.D.), the right dose for the baby can be established, he said.
“There’s no excuse for anyone not to know how to treat these babies,” Finnegan told ADAW. She developed the Finnegan score in the 1970s, and it is the state of the art for determining how to treat babies (currently done with oral morphine). “What is happening is they’re slow on starting the treatment, and they wait until the baby is in full blown withdrawal,” she said. “The point is to titrate the medication up, and then the baby is stabilized, and then to titrate it down.” Many physicians keep the baby on the morphine too long, she said.
Finnegan, a pediatrician, supports the rooming-in and breast-feeding promoted by Abrahams. “These babies need consoling,” she said. “The worst place to put these babies unless they are seriously sick is the NICU, with all the noise and lights,” she said. Also, they are left alone in the NICU because in fact babies with NAS are not seriously sick, she said. “No baby can die from NAS. If they’re screaming in the nursery it’s because you haven’t treated them properly.”
Of particular concern is any withdrawal in the mother while she is pregnant, which could result in hypoxia, said Finnegan. That’s why long-acting opioids like methadone and buprenorphine are ideal, supplying a steady state of medication.
Newman is also concerned that the “addict” label will stick with the child forever. “When somebody in a preschool exam opens up a child’s record and thinks, ‘Oh, this is an addicted baby,’ that label can have consequences right then.”
Newman recalled that the feared consequences for “crack babies” never happened, but that newspapers didn’t go back and write stories saying that these articles were wrong. “I’m afraid we’re going to see the same thing here,” he said. “We have to recognize that this is unequivocally a medical condition, and the focus should be on making maintenance treatment available and accessible to every woman.”
For more about NAS and the Finnegan score, go to www.neoadvances.com.