Increase Awareness of the Risks of Substance Use and Neonatal Abstinence Syndrome (NAS)

Introductory Paragraph

Opioid use during pregnancy can affect women and their babies. Women may use opioids as prescribed, may misuse prescription opioids, may use illicit opioids such as heroin, or may use opioids (opioid agonists and/or antagonists) as part of medication-assisted treatment for opioid use disorder. Regardless of the reason, women who use opioids during pregnancy should be aware of the possible risks during pregnancy, as well as the potential treatment options for opioid use disorder.

Key Information

Opioid use in women aged 15–44 years has increased over time. This increase is similar to the dramatic increase in overall use in the United States. During 2008–2012, about 1 in 3 reproductive-aged women filled an opioid prescription each year. As such, opioid use during pregnancy is not uncommon. There have been significant increases in opioid use disorder during pregnancy. For example, the number of women with opioid use disorder at labor and delivery more than quadrupled from 1999 to 2014. Opioid exposure during pregnancy has been linked to some negative health effects for both mothers and their babies. These include maternal death and poor fetal growth, preterm birth, stillbirth, possible specific birth defects, and neonatal abstinence syndrome. Birth outcomes for infants exposed to opioids during pregnancy include an increased likelihood to:

• Be born preterm (born before 37 weeks of pregnancy)
• Have poor fetal growth
• Have longer hospital stays after birth
• Be re-hospitalized within 30 days of being born
• Possibly be born with birth defects

The effects of prenatal opioid exposure on children over time are largely unknown. However, using opioids as prescribed or for treatment of opioid use disorder during pregnancy may be necessary and may outweigh the risks of these potential negative health outcomes.

Neonatal Abstinence Syndrome

Opioid use and medication assisted treatment for opioid use disorder during pregnancy can lead to neonatal abstinence syndrome (NAS) in some newborns. NAS is a group of conditions that can occur when newborns withdraw from certain substances including opioids that they were exposed to before birth. Withdrawal caused by opioids during the first 28 days of life is sometimes also called neonatal opioid withdrawal syndrome (NOWS). Withdrawal symptoms in newborns usually occur 48–72 hours after birth. Drug withdrawal symptoms may include:

• Tremors (trembling)
• Irritability, including excessive or high-pitched crying
• Sleep problems
• Hyperactive reflexes
• Seizures
• Yawning, stuffy nose, or sneezing
• Poor feeding and sucking
• Vomiting
• Loose stools and dehydration
• Increased sweating

The symptoms a newborn might experience, and how severe the symptoms will be, depend on different factors. Some factors include the type and amount of substance the newborn was exposed to before birth, the last time a substance was used, whether the baby is born full-term or premature, and if the newborn was exposed to more than one substance before birth.

Relevant Research

• Opioid Use and Opioid Use Disorder in Pregnancy This report provides an extensive literature review and includes recommendations and conclusions from the American College of Obstetricians & Gynecologists.

• Longer-Term Developmental Outcomes. There is limited information about longer-term outcomes of children exposed to opioids prenatally, including those with or without NAS. Not all babies exposed to opioids during pregnancy experience signs of NAS, but they may still have longer-term outcomes not obvious at birth. Results from a recent study suggest that children with NAS were more likely to have a developmental delay or speech or language impairment in early childhood, compared with children without NAS. It is not clear if these impacts are due to opioids specifically, other substance exposures, or other environmental influences. Findings about long-term outcomes of children exposed to opioids during pregnancy are inconsistent. More research is needed to better understand the spectrum of possible outcomes related to opioid exposure during pregnancy.

• This article titled "Narcotic Addiction, Pregnancy, and the Newborn," provides a 19-year overview of cases at one hospital. Although it is dated (1978), it potentially provides a baseline for comparison to conditions five decades ago.

Impactful Federal, State, and Local Policies

• Medicaid. Numerous Medicaid authorities, including the state plan, waivers, and other demonstration programs, can be used to provide SUD treatment and recovery support services to pregnant women with SUD as well as specialized services for infants with NAS.

• West Virginia. has a state plan amendment on NAS services that provides for an all-inclusive prospective bundled payment based on the daily treatment of Medicaid beneficiaries.

• The Guttmacher Institute tracks state laws and policies legislation and policies regarding substance use during pregnancy.

Available Tools and Resources

• The American College of Obstetricians and Gynecologists(ACOG) has published a report titled, "Opioid Use and Opioid Use Disorder in Pregnancy." This provides recommendations and clinical guidance. They also provide a FAQ sheet on "Opioid Use Disorder and Pregnancy" that identifies the most effective treatment for opioid use disorder during pregnancy to be opioid replacement medication, which includes medication-assisted treatment such as methadone and buprenorphine. The FAQ sheet also covers ways that behavioral therapy and counseling can assist with providing support and tools for ongoing recovery.

The Council on Recovery operates the Center for Recovering Families, a program that guides people who are seeking help to lasting and fulfilling recovery.

• The National Center on Substance Abuse and Child Welfare (NCSACW) is a technical assistance resource.

• SAFE Project has a dedicated online resource page titled, "Addiction and Mental Health Resources for Women." This includes a variety of resources specifically providing support during pregnancy.

• SAMHSA has published "Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants." This provides comprehensive guidance for optimal management of pregnant and parenting women with opioid use disorder and their infants.

• The University of Baltimore has published "Supporting Mothers and Infants Impacted by Perinatal Opioid Use: A Cross-Sector Assessment." This collaborative assessment resulted from a community-level intervention initiative that was funded by the Center for Drug Policy and Enforcement. The report provides information on process, lessons learned, and resources that may help others engaged in similar projects and collaboratives.

Promising Practices

Baptist Health System The Baptist Medical Center in San Antonio is a nationally recognized Center of Excellence for NAS Care.

Maternal Opioid Misuse (MOM) Model is promoted through the Center for Medicare and Medicaid Innovations. The primary goals of the MOM Model are to:

• improve quality of care and reduce costs for pregnant and postpartum women with OUD as well as their infants;
• expand access, service-delivery capacity, and infrastructure based on state-specific needs; and
• create sustainable coverage and payment strategies that support ongoing coordination and integration of care.