Neonatal Abstinence Syndrome (NAS)
Neonatal Abstinence Syndrome (NAS)
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Angela La Dow
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The name of the condition is Neonatal Abstinence Syndrome (NAS). The baby will be born with opioids on board and will require opioids or partial opioid receptor agonists to help the baby through withdrawl and detox. This process can be started while in utero with the mother in medication assisted treatment (MAT). The idea behind MAT is to use opioid agonists that do not fully cover the opioid receptors thereby reducing the euphoria of the full opioid (morphine, hydrocodone, fentanyl, oxycodone, & heroin). There are three treatment modalities for MAT; methadone, buprenorphine or the combo buprenorphine/naltrexone (Suboxone), and naltrexone itself (SAMHSA, 2018
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). Buprenorphine in combination with naltrexone completely blocks the full receptor so the effects can not be overcome by more opioids (to a certain extent) and reduces cravings. Once a patient is in MAT and dosed appropriately with a Suboxone dose that is the smallest dose to keep withdrawl away visits can be extended out if they are working therapy and group therapies such as NA and AA the psychosocial aspect of addiction. When a pregnant women starts MAT the amount of medication that crosses the placenta is the same as the mother’s and the fetus can start to slowly and safely reduce their exposure to full opioids (McQueen and Oikonen, 2016
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). A patient has to be off full opioids for at least 3 days before starting MAT with Suboxone. They are given Imodium, gabapentin, and clonidine to help reduce the withdrawl symptoms. If they are not they will go into full withdrawl with the initiating dose due to the naltrexone.
Risks for the baby are low birth weight, STI infections, potential abuse and neglect, and preterm birth (McQueen & Oikonen, 2016). Opioid withdrawl for infants is more serious that opioid withdrawl for adults due to the seizures and other neurologic symptoms it can cause. Depending the type of opioid and the amount taken by the mother the severity of withdrawl will be different for each infant. There will be tremors, diarrhea, irritability, tachycardia and tachypnea, poor feeding, and possibly seizures (McQueen and Oikonen, 2016). Long-term effects of NAS are not well studied but it has been found that there can be some behavioral problems and mental health issues with these children as well as abuse and neglect by the parents (McQueen and Oikonen, 2016).
There is a misconception that a women will automatically be placed in jail if the are using opioids while pregnant once they give birth so they do not seek prenatal care and sometimes will wait until they are in labor to be seen. There was on NAS infant in the hospital I work at who was born to the girlfriend of a MAT patient we were seeing. She left the hospital AMA because she did not tell anyone she was a heroin addict and started withdrawl. She could have been treated appropriately in the hospital and reduced her risk of hemorrhage and death and stayed with her baby. The goal for these women is to get them to bond with the baby, be able to manage their care in their home, and find supports for them over the long term (McQueen and Oikonen, 2016).
My last preceptor became certified in addiction treatment with Suboxone so I got the opportunity to work with this population and see first hand the initiation of treatment, pride in getting clean, pride in staying clean, and the disappointment of relapse. There are not a lot of providers that are certified to do this treatment and they are only allowed a certain amount of patients per provider. The certifying body that maintains it just opened certification to NPs and PAs to manage patients. Generally recreational drug use and alcohol abuse escalates to heroin use. I saw at least four patients that started with legit prescriptions for opioids and progressed to heroin use. The others started with other recreational drug use and alcohol abuse. My last preceptor stated to me that if a pregnant women seeks MAT and is on it while in labor there are better outcomes for the baby and the mother and child protective services may be willing to work with her.
References
McQueen, K., & Oikonen, J. (2016). Neonatal Abstinence Syndrome. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMra1600879
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SAMHSA. (2018). Medication assisted treatment. Retrieved from https://www.samhsa.gov/medication-assisted-treatment
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