I brainstormed possible solutions and chose which solution I believe would solve the problem on reducing neonatal substance exposure. Pharmacological risk factors of prenatal substance exposure
Risk factors for developing neonatal withdrawal syndrome include the type of drugs used, the duration of use, and gestational age. The pharmaceuticals causing NWS are classes such as opioids, barbiturates, antiepileptic, and benzodiazepines. Opioid analgesics are used in pregnant mothers to manage and treat opioid addiction, aid withdrawal symptoms and reduce fetal distress. Methadone and Buprenorphine (Opioid Analgesics) are considered “the standard of 2 care for treating opioid addiction in pregnancy and seem to be associated with a higher incidence of clinically significant NWS when compared to illicitly used opioids.” This suggests that opioid analgesics may still be addictive to the fetus, thus producing NWS. Antiepileptic drugs also need to be decreased once the patient becomes pregnant due to withdrawal risks. There has also been a connection to NWS in mothers using SSRI’s to treat depression. In 2012 Jansson and Velez wrote an article called Neonatal Abstinence Syndrome; Current Opinions in Pediatrics, discussing the possibility of SSRI’s causing NWS. They came to the conclusion that it is difficult to distinguish the difference between NWS and serotonin toxicity in neonates, and that it may be a combination of both. Gestational age is also a factor in NWS because “of the central nervous system (CNS) immaturity and or lower fat deposits in the premature infant”.
Prenatal and perinatal care
The goal of prenatal care is to first establish a trusting relationship, promote fetal health and safety through primary health care, and to detect and prevent potential problems. Diagnostic and screening procedures will include initial lab tests in which a drug screen is ordered via urine or blood. Drug test results will then be reviewed, and positive results warrant further investigation and proper medical documentation. Rebecca Stone (2015) argues that prenatal substance use is a public health and criminal justice concern. She states that “The effect of stigmatization, discrimination and fear of punishment present a barrier to wanted care. This creates a health risk, since substance-using women who do receive prenatal care experience more positive birth outcomes and have greater opportunities for other health promoting interventions than women who do not receive care.” Is our goal to merely identify and punish the addicted, or is it to help heal and provide unconditional care? Since the rate of substance exposed infants 3 increases Prenatal drug users will avoid care potentially reducing their neonatal health in exchange for possibly not criminally punished.
“As suggested by the AAP guidelines, there remains a lack of evidence to support the use of any one specific evaluation strategy to identify NWS.” One assessment tool most commonly used is conducting maternal interviews to target prenatal drug use. This assessment tool can negatively affect the “bond between mother and infant,” because the “nurse- mother relationship is strained.” Although nursing practice should be non-discriminatory and non-judgmental, mothers have shown to feel judged, and felt like the infants’ abstinence scores are based on whether the nurse likes the mother or not.
Toxicology screenings through the urine, meconium, cord tissue (etc.) are initiated in suspected cases. Even if the toxicology report shows a negative result, it “does not rule out maternal substance abuse nor does positive screening confirm abuse or addiction.” There are very sensitive timing requirements and identification methods that are needed for accurate testing, so very commonly toxicology screening is difficult to determine NWS alone.
Neurobehavioral assessment tools are the most commonly used to assess the severity of withdrawal in infants. Most of the time it will be based on a numerical system in which it is evaluated and charted for results. There are several different systems and tools to use when assessing. An article titled Psychometric evaluation of the Sophia Observation Withdrawal 4 Symptoms Scale in critically ill children states that “several pediatric withdrawal scales have been developed to evaluate opioid and benzodiazepine abstinence; however, none have been identified as valid for neonatal use.”
Methods of treatments
When an infant is born showing signs of withdrawals the primary goal is to ensure adequate nutrition and sleep. Nonpharmacological interventions include “comfort care” targeted to position with swaddling, therapeutic tucking, soothing techniques, nonnutritive sucking, gentle rocking, massage, and minimal stimulation environments. Medications used for NWS are oral morphine (most common), methadone, and buprenorphine.
Barriers to successful NWS treatment
Nonpharmacological comfort care can be paired up with pharmacological measures for the best outcome, but because of certain legal circumstances, custody can be immediately revoked from the mother. This can lead to a more difficult coping process, prolonging the hospital stay for the infant as it is difficult to find 24/7 neonatal comfort care volunteers. Another barrier to successful neonatal withdrawal symptom treatment is the mother’s fear of being punished for using during pregnancy, which leads to more mothers avoiding prenatal care all together.
Analyzing information on neonatal withdrawal syndrome
Currently opioids, barbiturates, antiepileptics, and benzodiazepines have been proved to cause neonatal substance exposure that results in neonatal withdrawal syndrome. Extensive studies are needed to define if other pharmaceuticals such as SSRI’s and opioid analgesics can cause NWS. The unresolved problem of NWS seems to stem from neonatal substance exposure 5 in general. This problem should be promptly addressed during family planning and prenatal care to avoid fetal substance exposure to begin with.
Current opioid use prevention methods
On September 16, 2016 The Whitehouse Statements and Releases state that in 2016 1.1 billion dollars in grants were given to the states by the Congress. The money was given to provide better more available treatment centers for citizens who wanted to detox and recover from pharmacological addictions. Morbidity and Mortality Weekly Report (MMWR) written in March 2017, the CDC states that their primary prevention strategies (2016) on lowering neonatal substance exposure are to require the prescriber to explain the black box warnings, long term effects, and family planning and preconception care. The CDC constantly monitors prescription drug use with each state’s Prescription Drug Monitoring Programs (PDMP). The CDC’s strategy on treating current mothers with an opioid addiction is to medically taper the opioids with methadone or buprenorphine. Although few states statistically record how many cases of neonatal substance exposure occurs, the states who have released data show that despite the efforts, the rate is steadily increasing.
Barriers of opioid use prevention methods
Barriers of opioid use prevention would include birth control regimen noncompliance. Although the CDC states their strategies that include family planning, never does it state that a birth control method(s) and or pregnancy test is required before prescription. The success rate of birth control varies and is greatly dependent on proper medication regimen. A barrier to detox treatment would be the fear of legal punishment. There are not any laws or set of policies approved by the government for the requirement and strict encouragement of a medical detox/pharmacological tapering program either, so mothers continue to use without seeking treatment or prenatal care in general.
I know that addicts typically have learned-helplessness and in most cases, are unable or unwilling to judge what is best for their prenatal health, and future fetal health. For cases of prenatal drug addiction, there needs to be set laws or policies for the prescriber to follow every time they prescribe addictive pharmaceuticals that can cause neonatal withdrawal syndrome. The requirement of birth control should be verified before each prescription to attempt reducing neonatal substance exposure. Tapering addictive medications should also be a strict requirement that physicians participate in with the help of medical detox facilities. In the past, mothers have felt threatened by law enforcement policies on illicit drug use during pregnancy, and the perception of drug addicted mothers needs to change. Punishment and shame should be replaced with encouragement and guidance.
So far, we know that tolerance levels increase as drugs are used for longer periods of time, resulting in higher doses, and more cases of neonatal substance exposure which lead to NWS. In conclusion, the problem of neonatal substance exposure should be aggressively addressed during family planning and prenatal care to avoid fetal substance exposure all together. Mandatory laws and policies should be set in place before each prescription renewal to avoid and detect pregnancy in women who are prescribed addictive pharmaceuticals that pose a possible threat to fetal health. Aggressive strategies to taper such pharmaceuticals in pregnant women should also be implemented with unconditional care to encourage addicted mothers and limit fear.