More newborns showing ill effects of maternal opioid use

Many newborns wail inconsolably in the Knoxville, Tenn., neonatal intensive care unit where Mark S. Gaylord, MD, works.

They often sweat with fever and struggle to breathe. The skin on their bottoms cracks from diarrhea. In more serious cases, they have seizures and remain hospitalized for up to two months.

The diagnosis for these babies is neonatal abstinence syndrome, a group of problems caused by maternal opiate use during pregnancy. The incidence of such cases has nearly tripled in the past decade, data show.

In 2009, the syndrome was diagnosed in newborns at a rate of 3.4 per 1,000 hospital births per year. That was up from 1.2 diagnoses per 1,000 births per year in 2000.

“It was a common problem in the 1980s [to have babies born to mothers addicted to crack cocaine], but it didn’t fill up hospital beds like what I’m seeing now,” said Dr. Gaylord, a neonatologist at the University of Tennessee Medical Center. “It’s not just a problem for all those poor folks or just for people in East Tennessee. This is a systemic problem from rich to poor, white to black and Latino.”

Neonatologists say it is unclear what percentage of neonatal abstinence syndrome cases are due to mothers appropriately taking opioids that were prescribed to them and how many cases are caused by mothers using the drugs illicitly. But they agree that the rise in use and abuse of pain medications in the United States likely is contributing to the rise in diagnoses.

Health professionals and policymakers are grappling with ways to remedy the abuse problem as addiction to prescription painkillers is occurring at alarming rates. More than 40 states have implemented prescription drug monitoring programs that identify patients who receive opioids from multiple physicians. In Florida, where prescription drug abuse and neonatal abstinence syndrome diagnoses are particularly high, the state Legislature passed a bill this year that calls for a task force to evaluate the extent of the syndrome among the states’ infants.

Health professionals say primary care doctors nationwide should be prepared to care for these children and their mothers. But even if family physicians and internists do not have pregnant patients who are taking opioids, they can help keep the problem from escalating, experts say.

For example, before prescribing an opioid to women of childbearing age, physicians should discuss the potential negative health effects the drug could have on a fetus if the patient becomes pregnant, said Mark L. Hudak, MD, a neonatologist at the University of Florida College of Medicine-Jacksonville.

Addiction psychiatrist David Sack, MD, encourages doctors to consider giving a urine toxicology screen to all pregnant women to identify any who are abusing opioids. He said some physicians might hesitate to conduct such testing routinely, because many states require doctors to report a pregnant woman’s drug abuse to social services. But he said the urine toxicology screen is effective in identifying substance abuse and ultimately will help ensure the health of the unborn child.

“We need to be clear that this is an illness, and we need to help and support these women so they can have healthy babies,” said Dr. Sack, CEO of California-based Elements Behavioral Health, which offers addiction treatment programs at facilities across the country.

Opiate use climbing in pregnant women

Nationally, an estimated 13,539 newborns had neonatal abstinence syndrome in 2009 compared with 4,682 babies in 2000, according to a study published online April 30 in The Journal of the American Medical Association. To put that in perspective, about one child born every hour had the syndrome, said lead study author Stephen W. Patrick, MD, MPH.

The increase is significant, because it is occurring in a population that usually has no health complications, said Dr. Patrick, a fellow in the University of Michigan Health System’s Division of Neonatal-Perinatal Medicine. The number of pregnant women who were dependent on or using opiates when they delivered climbed from 4,839 in 2000 to 23,009 in 2009, he said.

Researchers did not identify the types of opiates mothers were using, such as heroin, methadone or pain relievers, Dr. Patrick said. But, he added, “We know in the general population opioid pain reliever use and abuse has grown substantially. Probably some of the increase we’re seeing [in the JAMA] study is attributed to opioid pain relievers.”

Nationally, about 12 million Americans age 12 and older took prescription pain medications for nonmedical reasons in 2010, according to the Centers for Disease Control and Prevention. Overdose deaths from these drugs in the U.S. have nearly quadrupled in the past decade. In 2008, opioid prescription painkillers were involved in 14,800 drug overdose deaths, up from 4,000 in 1999, the CDC said.

The increase comes as national sales of opioid pain relievers to hospitals and elsewhere continue to climb. Sales rose from 1.8 kg per 10,000 people in 1999 to 7.1 kg per 10,000 people in 2010, the CDC said.

Contributing to the abuse of pain relievers is the belief among some patients that prescription drugs are safe because they are administered by physicians and manufactured in legitimate factories, Dr. Sack said. There also are some well-meaning doctors who are misinformed about the benefits and downsides of opioid pain relievers and thus overprescribe the drugs, health professionals say.

In many instances, women taking painkillers during pregnancy were prescribed the drugs at earlier points in their lives and got addicted to them, Dr. Gaylord said.

Pain medicine specialists point out that pain medications can have an appropriate role during pregnancy. “It’s not bad to be on opioids when you’re pregnant if you have good care,” said pain medicine specialist Lynn Webster, MD. He added that more research is needed to determine if women are being treated with opioids appropriately and how pregnancy outcomes would be affected without the drugs.

“There are consequences of not addressing pain in women who are pregnant. That has to be kept in mind,” said Dr. Webster, president-elect of the American Academy of Pain Medicine.

Yet health professionals worry that as abuse of opioids continues to escalate, more babies will be born with neonatal abstinence syndrome, and there is limited information about the long-term health effects of in utero exposure to these drugs.

“When moms [who took opioids during pregnancy] ask me, ‘What did I do to my baby?’ I tell them, ‘This can’t be good for their developing brain,’ ” but doctors don’t know exactly how the baby will be affected, said Jonathan Wispe, MD, a neonatologist at Nationwide Children’s Hospital in Columbus, Ohio.

Many with syndrome go unidentified

Babies with neonatal abstinence syndrome often do not begin showing signs of withdrawal until two to three days after birth, depending on when the mother last took the opioid and how much she consumed, Dr. Wispe said. That means there are many babies physicians are unable to identify because the mother and child are released from the hospital before the symptoms appear, he said.

When a baby is diagnosed with neonatal abstinence syndrome, the newborn is kept in an area with low light and little noise, and is held and rocked by nurses and volunteers. The length of the hospital stay can vary from a week to two months.

When the child is released, care often falls to a general pediatrician. Dr. Wispe encourages such doctors to look for signs of withdrawal that can recur in newborns and to link them to specialized care if developmental delays are identified as they get older.

Health professionals agree that family physicians and internists should ask patients in a nonjudgmental way about whether they use prescription or illicit drugs. They also recommend that primary care doctors regularly talk to pregnant patients about the potential harms in drinking alcohol, smoking and using prescription opioids and some over-the-counter medications.

But some experts hesitate to suggest universal urine toxicology screening for all pregnant patients, due in part to the time it would take. A positive test also could prompt social services agencies to get involved.

Instead, several neonatologists interviewed for the story suggest screening individuals who have an increased risk of substance abuse, such as those whose parent or partner abuses prescription or illicit drugs.

“It is a diverse group of mothers who are addicted to opiates. Some of them are abusing street drugs,” Dr. Patrick said. “Some are being treated for chronic pain and others are in methadone treatment programs. Because of that [diversity], this is a complex issue that is going to require answers that are not simple.”