Newborn Opioid Withdrawal Requires a 'Cascade of Care,' Study Suggests

Effective management of neonatal abstinence syndrome (NAS) -- withdrawal symptoms occurring in infants exposed to opioids in utero -- requires a coordinated "cascade of care" from prevention through long-term follow-up, reports a study in Advances in Neonatal Care, official journal of the National Association of Neonatal Nurses. The journal is published in the Lippincott portfolio by Wolters Kluwer.

Based on interviews with frontline providers caring for infants affected by NAS, the researchers identify four essential areas to improve care for this increasingly common complication of opioid use. "Greater resources, coordination, and cross-disciplinary education are urgently needed across the cascade of care to effectively address NAS," write Jennifer L. Syvertsen, PhD, MPH, of the University of California, Riverside and colleagues at the University of Southern California.

Critical Areas to Improve Care for Infants Exposed to Opioids

Neonatal abstinence syndrome (NAS) can result from legally prescribed opioid medications, misuse of prescription opioids, illicit drugs such as heroin, or medication-assisted therapy to treat opioid use disorders, including Suboxone or methadone. Infants exposed to any of these forms of opioids during gestation are at risk of NAS, developing signs and symptoms of opioid withdrawal after birth. Timely and effective care can lower the impact and costs of NAS. However, standardized care and treatment resources are often lacking, both for women and their infants affected by NAS.

The researchers conducted in-depth interviews with 18 central Ohio healthcare providers caring for infants and families affected by NAS. Ohio has among the highest rates of opioid use and NAS in the United States. In 2015, nearly 2,200 infants were hospitalized for NAS, at a cost of over $133 million. "Rather than an acute diagnosis, we propose that NAS is better conceptualized as cascade of care -- and there is a need to better coordinate and provide care at each stage of the cascade," Dr. Syvertsen and coauthors write. Informed by analysis of the provider interviews, the researchers discuss four interrelated components of the cascade of care:

• Prevention. Care begins with preventing the misuse of opioids and other drugs. Preventive efforts should encompass the "social determinants of health" such as poverty, lack of education, and limited opportunities. "Although there is an urgent need for prevention programming and drug treatment, current resources do not meet the demand," the researchers write.

• Prenatal Care and Drug Treatment. The providers stressed the need for supportive care for pregnant women using opioids, rather than punitive approaches. While comprehensive care programs have yielded promising results, NAS can occur even in infants born to mothers receiving recommended medication-assisted treatment for opioid use disorder. "Barriers in communication and a shortage of integrative prenatal programs to address opioid use in pregnancy often leave women confused and frustrated about a subsequent NAS diagnosis at the hospital," Dr. Syvertsen and colleagues write.

• Labor and Delivery. Infants must be monitored for signs of NAS, with treatment if needed; providers stressed that consistency in following protocols is critical to reducing infant length of stay in the hospital. Programs to sensitize staff and mitigate stereotyping attitudes toward the mothers of babies with NAS have led to better care. In rural areas, the infant has to be transported to a higher-level newborn intensive care unit, creating barriers to mother-infant bonding.

• Aftercare. Supportive aftercare includes access to drug treatment and social services, monitoring the child's development, and providing a healthy home environment for the infant to thrive. The providers cited variations in policies and procedures, noting that available resources are stretched to the limit. While services are available for pregnant women, all too often they "shut down" after delivery.

"Our current focus on the period of pregnancy alone is insufficient to address the complexity of NAS," Dr. Syvertsen and colleagues write. Their article provides examples of interview quotes illustrating each of the four elements of the cascade of care and important subthemes.

Dr. Syvertsen and coauthors highlight the need for programs and policy at each stage of the cascade, toward the critical goal of stemming the tide of NAS. They conclude: "Unless we make a serious political commitment to create fair drug policy, adapt a more integrative approach to addressing NAS, and adequately support the initiatives that we know can work, NAS incidence will continue to rise and devastate communities."

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Journal Reference:

1. Syvertsen, Jennifer L.; Toneff, Hannah; Madden, Danielle R.; Clapp, John D. Conceptualizing Neonatal Abstinence Syndrome as a Cascade of Care: A Qualitative Study With Healthcare Providers in Ohio. Advances in Neonatal Care, 2018; DOI: 10.1097/ANC.0000000000000552