_________________________________________________________________________ Opioid Use Disorder
is used for infants with more severe expression of NOWS to allow them to feed, sleep, gain weight, and interact with caregivers [206]. Opioids are considered the first choice if pharmacotherapy is necessary [206]. Opioid treatment of NOWS reduces the time to regain birth weight, reduces the duration of supportive care, and increases the length of hospital stay. There is no evidence of effect on treatment failure [207]. Treatment with long-acting opioids has been shown to be superior to phenobarbital and diazepam in infants with NOWS [207]. Phenobarbital is gener- ally considered a second-line agent and is effective for the treat- ment of withdrawal and polydrug exposure. Clonidine is also a safe second-line option for treatment of NOWS symptoms that are refractory to opioid therapy [206; 209]. Buprenorphine and methadone have both been shown to be safe and effective treatments for opioid use disorder during pregnancy [210]. A meta-analysis showed that methadone was associated with higher treatment retention and buprenorphine resulted in a 10% lower incidence of NOWS, decreased neonatal treat- ment time of 8.46 days, and less morphine (3.6 mg) needed [211]. Infants whose mothers receive these medications may still experience NOWS; however, it is less severe than in the absence of treatment [211]. In treating pregnant women with substance dependence, psy- chologic and pharmacologic treatments are often combined. Psychosocial treatments include contingency treatment, com- munity reinforcement, behavioral marital therapy, cognitive- behavioral skills training, motivational enhancement therapy, and 12-step approaches [202].
OPIOID USE DURING PREGNANCY A portion of pregnant women with substance dependence continue using addictive substances despite awareness of the potential harm to the fetus [202]. Infants can sustain adverse effects from maternal opioid use, although it is difficult to separate factors due to opioid use from those due to the abuse of other drugs, poor prenatal care, poor nutrition, or other complications [103; 203]. Reports of adverse effects of opioid use on fetuses and neonates include [202]: • Fetal growth restriction • Intrauterine withdrawal with increased fetal activity • Depressed breathing movement • Preterm delivery • Preterm rupture of the membranes • Meconium-stained amniotic fluid • Perinatal death • Neonatal opioid withdrawal syndrome (NOWS) Opioid withdrawal is a physiologic rebound from the chronic drug effects on brain function. In pregnant women, rapid opioid withdrawal may precipitate preterm labor; in neonates, it may be fatal [202]. NOWS occurs when an infant becomes dependent on opioids or other drugs used by the mother dur- ing pregnancy [204]. It is an expected and treatable condition seen in 30% to 80% of infants born to women taking opioid agonist therapies [203]. According to hospital data from the National Inpatient Sample (covering 97% of the U.S. popula- tion), from 2004 to 2014, the incidence of NOWS among infants insured by Medicaid increased by five-fold (from 1.3 in 1,000 to 5.8 in 1,000 births). This is equivalent to diagnosing one newborn with NOWS every 25 minutes [204]. The increase in the incidence of NOWS has led to an increase in admission rates to neonatal intensive care units, from 7 per 1,000 to 27 per 1,000 cases, resulting in a an almost seven-fold increase in hospital costs ($462 million in 2014). Hospital charges tripled to $2.5 billion from 2012 to 2016 [204]. NOWS may result in disruption of the mother-infant relationship, sleep-wake abnormalities, feeding difficulties, weight loss, and seizures [204; 205]. Withdrawal symptoms in neonates can include tremors, diarrhea, fever, irritability, jitteriness, sweating, fever, vomiting, and generalized convulsions [204; 206; 207]. Although the optimal treatment for NOWS has not been established, The American Academy of Pediatrics recom- mends nonpharmacologic treatment as the first-line approach and continuing through hospital discharge [208]. The goal of nonpharmacologic treatment is to assist the self-organization of the neonate while maintaining the mother-infant dyad [208]. Because pharmacologic therapy can prolong hospitalization and expose the infant to additional agents that are often not necessary, it should be considered after supportive measures fail to ameliorate the infant’s withdrawal. Pharmacotherapy
The World Health Organization recommends that healthcare providers should, at the earliest opportunity, advise pregnant women dependent on opioids to cease their use and offer, or refer to, detoxification services under
HEROIN Heroin rapidly crosses the placental blood barrier. Between 55% and 94% of infants born to IV heroin users exhibit signs of neonatal withdrawal, with a small minority showing neo- natal seizure activity [212]. Methadone maintenance has been found to be an effective harm-reduction strategy and can reduce acute neonatal withdrawal problems, including seizures [213]. medical supervision where necessary and applicable. Detoxification can be undertaken at any stage in pregnancy, but at no stage should antagonists (e.g., naloxone, naltrexone) be used to accelerate the detoxification process. (https://www.who.int/publications/i/ item/9789241548731. Last accessed March 21, 2024.) Strength of Recommendation/Level of Evidence : Strong/very low
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MDRI2026
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