SUBSTANCE ABUSE/OPIOID WITHDRAWAL
Substance abuse during pregnancy has increased substantially over the past 10 years and has reached national, epidemic proportions. In the United States, approximately 225,000 infants yearly are exposed to illicit substances (MacMullen, Dulski, & Blobaum 2014). Retrospectively, by 2011, 1.1% of pregnant women abused opioids, pain relievers, and heroin; 12.9% were dispensed an opioid at some time during the pregnancy, and the incidence of infant withdrawal rose from 1.2 to 5.8 per 1,000 births (Hall et al., 2016). From the years 2000 to 2009, the number of infants in the United States diagnosed with neonatal abstinence syndrome (NAS) grew threefold, accounting for $720 million in national health care expenditures (Patrick et al., 2015). In response to the growth and variable treatment for infants, the American Academy of Pediatrics requested the medical community to standardize care delivered to infants withdrawing from opioids (Patrick et al., 2016).
NAS is a drug-withdrawal syndrome experienced by opioid-exposed infants shortly after birth (Patrick et al., 2016), with clinical signs that affect the central nervous system, as well as the autonomic, gastrointestinal, and respiratory systems. Legal use of tobacco and alcohol alone is harmful to the growing fetus, yet, when coupled with illicit drugs or opiates, it is difficult to extrapolate what substance or drug combinations are causing withdrawal. Because of the potential for multiple exposures, the data outcomes for infants are not conclusive and may be impossible to predict. In response to the increased incidence of infants experiencing NAS and a desire to optimize infant outcomes, collaborative neonatal groups combined strategies to develop evidence-based guidelines to treat NAS pharmacologically (Hall et al., 2014, 2016).
The health care team can anticipate withdrawal signs to develop if the mother is enrolled in a methadone clinic or substance abuse program and is receiving methadone or buprenorphine to treat her own withdrawal. However, it is difficult to anticipate infant withdrawal when there is no prenatal care or a poor maternal history. Pregnancy may be the first time a woman finds help for her addiction. Despite these challenges, most drugs and substances are known to cross the placenta and affect the fetus.
The effects of infant exposure to chemical substances were recognized more than 50 years ago, but fetal development has only been seriously studied in the past 30 years. Nicotine has been studied since 1960, alcohol since 1970, and illicit drugs since 1980. Marijuana is the most commonly used illicit substance during pregnancy with approximately 2.5% of women using during pregnancy, 220often concurrently with tobacco and alcohol. Therefore, isolated effects alone are difficult to study (Jaques et al., 2014). It is unknown whether the long-term effects of prenatal exposure to medicinal cannabis used in a controlled manner differ from the effects of cannabis used as a legal, recreational drug during pregnancy. However, follow-up developmental growth data report school-age children exposed to in utero marijuana exhibited decreased attention, hyperactivity, and impulsivity. Reading, spelling, and math skills were lacking particularly for those children who were heavily exposed to marijuana during the first trimester of pregnancy (Metz & Stickrath, 2015).
The exact mechanism by which nicotine produces adverse effects are unknown, but it is believed the vasoconstrictive effects on the placenta and umbilical vessels lead to fetal hypoxia resulting in poor infant growth and brain development (Behnke & Smith, 2013). Maternal excessive ingestion of alcohol during pregnancy may cause fetal alcohol syndrome. Infants may demonstrate neurodevelopmental deficits of poor habituation, subtle language delays, low levels of arousal with motor abnormalities, growth restriction, and potential for congenital anomalies (Behnke & Smith, 2013). Methamphetamine and cocaine long-term effects as potent vasoconstriction agents are unclear but suggest an association with prematurity and intrauterine growth restriction. Animal studies have shown disruptions in neural and glial cell organization, migration, and altered nucleic acid and protein production in the brain suggestive of overall compromise in brain growth (Behnke & Smith, 2013).
Of critical concern is maternal substance use on the developing fetal brain. During the embryonic stage, drugs can have significant teratogenic effects that persist as subtle effects of abnormal growth and maturation. Jaques et al. (2014), studied animal–cannabis-exposed models and suggested that during the animal embryonic stage, neurotransmitter pathways and receptors, particularly dopamine receptors, were disrupted. Disturbances in dopamine function have been associated with an increased risk of neuropsychiatric disorders such as drug addiction, schizophrenia, and depression. However, whether these changes are implicated in the future risk of addictive behaviors in the human is yet unknown (Jaques et al., 2014).
Acute narcotic withdrawal usually begins 24 to 48 hours after birth; however, symptoms may not appear until 3 to 4 days after birth. Methadone exposure symptoms may appear within 48 to 72 hours or may not be exhibited until 3 weeks of age. Readmission is common as infants are often discharged before symptoms appear. Opiate withdrawal develops in 55% to 94% of exposed infants (Hall et al., 2014). The infant with opiate NAS may exhibit hyperactivity; irritability; sleep disturbances; hypertonia and tremors; potential seizures; exaggerated Moro reflex; increased muscle tone; exaggerated sucking; high-pitched cry; diaphoresis; poor feeding; diarrhea; vomiting; poor weight gain; and overall poor orientation for self-regulation with autonomic signs of yawning, sneezing, nasal stuffiness, mottling of skin, and fever (Hudak, Tan, Committee on Drugs, & Committee on Fetus and Newborn, 2012). Nursing interventions alone for these symptoms often are not adequate treatment. The most commonly used therapeutic, opioid treatment for withdrawal is morphine, although some 221centers use methadone with emerging use of buprenorphine and clonidine as an adjunct therapy (Kraft & van den Anker, 2012).
The Finnegan Neonatal Abstinence Scoring System (NASS) is a tool initially established by Finnegan in 1975, modified, published in the standardized form, and used by nursing staff to assess an infant’s withdrawal symptoms and need for pharmacologic intervention (Asti, Magers, Keels, Wispe, & McClead, 2015). It is an easy, comprehensive scoring system composed of 21 items relating to signs of neonatal withdrawal and the predominant tool used in the United States.
The nursing assessment of interventions for nonpharmacologic therapy was gathered from systematic reviews of literature based on nursing case reports, descriptive or retrospective studies, nursing articles and reviews, or sometimes, based on the tradition of what seemed to work. A systematic literature review published by MacMullen et al. (2014) lists nursing interventions based on a level of evidence scale. Levels I to II have high-level evidence based on randomized control trials; level III evidence is based on retrospective cohort studies; and level IV evidence is based on case studies or observational reports.
The nursing assessment begins with a thorough maternal history to identify infants at risk. Maternal drug history and screening should be conducted for all pregnant women. Nurses use their center’s NAS scoring tool to identify infant signs and symptoms of withdrawal and closely monitor scores per protocol to determine initiation, escalation, weaning, or discontinuation of pharmacological therapy.
NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS
Nonpharmacologic nursing therapies based on the level of evidence are as follows: supportive care measures of swaddling, decreased stimulation, low-lighted environment, limiting noise; cluster care, sucrose pacifier, and cuddling or infant massage; swaying or rocking as appropriate based on evidence score, level IV, case series. Auditory and eye-to-eye contact in a randomized-control trial received a high level of evidence, levels I to II. Rooming-in as a retrospect, cohort study scored a level III. Nutritional deficiencies from increased energy expenditure, or vomiting, diarrhea, or loose stools require a high-calorie formula; poor oral skills, which may require intravenous therapy or gavage feedings, received an evidence level IV.
Nurses must record intake and output and serum electrolytes to indicate dehydration and/or deficiencies. Daily weight is an important indicator of nutritional status. Breastfeeding may be contraindicated in some instances; however, breastfeeding provides optimal nutrition and promotes maternal–infant 222bonding. Mothers on methadone therapy may breastfeed, which is supported by the American Academy of Pediatrics and per most institutions, as evidence levels III–IV. Skin care for any breakdown areas may require topical ointments, barrier shields of clear, transparent dressings over reddened areas, and positioning for comfort, as evidence level IV. Pharmacologic therapy is indicated for moderate-to-severe signs of NAS and is used to prevent complications of fever, weight loss, and seizures, or if the infant is not responding to nonpharmacologic therapies.
An infant born to a mother on a low-dose prescription opiate with a short half-life may be safely discharged if there are no signs of withdrawal by 3 days of age, whereas an infant born to a mother on an opiate with a prolonged half-life should be observed for a minimum of 5 to 7 days after cessation of pharmacologic therapy. Methadone withdrawal signs may continue for months, but late signs are often subtle and only require comfort measures as treatment. Because initiation of the 2012 American Academy of Pediatrics calls for an evidence-based protocol for NAS, outcomes to date are favorable. Use of a stringent protocol for pharmacological therapy has reduced the duration of opioid exposure and length of hospital stay, with continued research to refine the pharmacological weaning protocol in progress (Hall et al., 2014).
Nursing protocols based on evidence-based research versus systematic reviews are valuable in refining nonpharmacological therapies to treat NAS. Family-centered, rooming-in models of care are showing favorable outcomes in shortening opioid treatment for NAS and thus decreasing the length of stay. Nurses must continue to be active participants in NAS protocol development through participation in committees to evaluate literature, and create policies and procedures to refine nonpharmacologic treatment for NAS. Therapy for NAS begins at the bedside with the nursing assessment and is the integral component that determines therapy and, ultimately, the outcome.
There is a need to disentangle the many variables of substances and drugs associated with newborn exposure, withdrawal, and follow-up care. The harmful effects of any substance or drug use on the fetus and newborn are well documented. The short- and long-term effects of drug use on infant growth and development are uncertain. Health care has responded by researching pharmacological and nonpharmacological interventions to minimize withdrawal, minimize the risk of adverse outcomes, and shorten the length of hospital stay to minimize health care costs. Until there is a significant decrease in drug abuse during pregnancy, hopeful outcomes rely on health care’s dedication to research that results in effective methods and therapies to treat NAS.