Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants

The opioid epidemic carries with it another epidemic, this one of infants born with neonatal abstinence syndrome (NAS), stemming from in utero exposure to opioids. NAS is characterized by withdrawal symptoms such as tremors, irritability, poor feeding, respiratory distress, and seizures.  In a recent day-long course at Penn sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), health professionals came together to learn how to screen for, diagnose, and treat pregnant mothers with opioid use disorder (OUD) and infants with NAS.

Held at Penn’s Smilow Center for Translational Research, the course, Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants, was co-hosted by LDI,  the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH), and the Helen O. Dickens Center for Women’s Health at the Hospital of the University of Pennsylvania. The diverse audience included social workers, pharmacists, and medical providers with backgrounds in obstetrics, family practice, pediatrics, and infectious disease.

Trina Salva, MD, Medical Director at the Helen O. Dickens Center for Women’s Health, set the stage for the event, saying, “We need to equip ourselves with the tools to help our patients the best we can. More and more we are seeing opioid use disorder not just in our pregnant patients, but their families and our own.”

SAMHSA Region III Administrator Jean Bennett, PhD, moderated the course and emphasized the importance of the interactive curriculum. “You will get great information today, but this is only the beginning of a conversation. Not just with our amazing faculty, but with your neighbors in this room.”

The curriculum included six modules providing up to date information on OUD in pregnant women, pharmacotherapy, prenatal care, preparing for labor and delivery, infant care, and postnatal care.

Co-Facilitator Carrie Malanga, RN, PMHNP-BC, a psychiatric mental health nurse practitioner and Clinical Director for Mothers MATTER, discussed prenatal care, including OUD and Substance Use Disorder (SUD) screening tools. She highlighted that pregnant women should be universally screened for SUD, as early as possible, to get the appropriate care and referrals to specialized treatment. Ideally, Ms. Malanga noted, an individualized treatment plan would be developed through a coordinated team of healthcare professionals including OB/GYNs, SUD treatment specialists, nurses, case managers, peer recovery coaches, and the patient.

Co-Facilitator Stephen Patrick, MD, a practicing neonatologist and Director of the Center for Child Health Policy at Vanderbilt University School of Medicine, discussed the benefits of medications for OUD during pregnancy. Opioid detoxification or withdrawal is not recommended during pregnancy.  Stabilization on medications for OUD minimizes opioid withdrawal, reduces cravings, and high-risk behaviors, such as intravenous drug use.

According to SAMHSA guidelines there is no evidence that buprenorphine and methadone cause an increase in birth defects and these medications likely have minimal long-term neurodevelopmental impact. Prenatal education, smoking cession, and breastfeeding are recommended interventions to manage the incidence and severity of NAS and mitigate long-term risk. Dr. Patrick also explained the importance of adjunct therapies such as behavioral therapy and peer support, which has been shown to increase retention in treatment programs.

In infants, NAS is an expected and treatable condition that often follows prenatal exposure to opioids. The number of mothers with OUD at time of delivery more than quadrupled between 1999–2014 in the United States. Between 50-80% of opioid-exposed infants will develop NAS. Multiple factors contribute to the development of NAS, including the opioid type and polysubstance use. In the US, an infant is born with NAS every 15 minutes.

Course participants learned about validated NAS scoring scales, such as the MOTHER NAS Scale, that can determine NAS severity and guide treatment decisions. They learned that consistency is the key to treating these infants; standard protocols have been associated with a reduced length of opioid exposure and hospital stay for infants with NAS.

As continuing medical education, the course accomplished its objective to present participants with best practices for treating pregnant women with OUD.  But it may have accomplished even more than that: by educating medical providers, it may encourage some to get waivered to prescribe buprenorphine and others to advocate against punitive policies that discourage women from seeking treatment.