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

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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 her potential treatment options for opioid use disorder.

Key Information

Opioid Use During Pregnancy

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. [1] 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. 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 outweigh the risks of these potential negative health outcomes.

Neonatal Abstinence Syndrome (NAS)

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.

Birth Outcomes Associated with Opioid Use During Pregnancy

Infants exposed to opioids during pregnancy might be more likely 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; and
  • Possibly be born with birth defects.

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 studyexternal icon 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. Findingsexternal icon 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.

The American College of Obstetricians & Gynecologists (ACOG)[2] has published Frequently Asked Questions (FAQs) regarding Opioid Use Disorder (OUD) during pregnancy. They identify the most effective treatment for opioid use disorder during pregnancy as opioid replacement medication, behavioral therapy, and counseling. This includes medication-assisted treatment such as methadone and buprenorphine. Behavioral therapy and counseling assist with providing support and tools for ongoing recovery.

Relevant Research

Narcotic Addiction, Pregnancy, and the Newborn[3]

Opioid Use and Opioid Use Disorder in Pregnancy[4] Includes recommendations and conclusions from the American College of Obstetricians & Gynecologists.

Impactful Federal, State, and Local Policies

Medicaid for SUD Services and Treatment of NAS[5] 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’s State Plan Amendment on Neonatal Abstinence Syndrome Treatment Services[6] NAS services are paid for via an all-inclusive prospective bundled payment based on the daily treatment of Medicaid beneficiaries.

State Laws & Policies[7] legislation and policies regarding substance use during pregnancy provided by Guttmacher Institute.

Available Tools and Resources

Supporting Mothers and Infants Impacted by Perinatal Opioid Use: A Cross-Sector Assessment[8]-A collaborative assessment funded from the Center for Drug Policy and Enforcement at the University of Baltimore through the Community-level intervention initiative. It was noted the two main objectives of the report include:

  • to provide the results of the assessment and recommendations
  • to provide information on our process, lessons learned, and resources that may help others engaged in similar projects/collaboratives.

National Center on Substance Abuse and Child Welfare (NCSACW)[9]-a technical assistance resource

Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants[10] SAMHSA Clinical Guide providing comprehensive and national guidance for optimal management of pregnant and parenting women with opioid use disorder and their infants.

Opioid Use and Opioid Use Disorder in Pregnancy[11] The American College of Obstetricians and Gynecologists(ACOG) recommendations and clinical guidance surrounding Opioid Use Disorder in Pregnancy.

American College of Obstetricians and Gynecologists- Frequently asked questions on Opioid Use Disorder and Pregnancy[12]

Safe Project Addiction and Mental Health Resources for Women[13]

Promising Practices

The Council on Recovery[14] Center for Recovering Families Program guides people who are seeking help to lasting and fulfilling recovery.

Baptist Health System[15] Baptist Medical Center in San Antonio is a nationally recognized Center of Excellence for NAS Care.

Maternal Opioid Misuse (MOM) Model[16] 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.