North Carolina Pregnancy & Opioid Exposure Project

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Imagine being in a room filled with more than four hundred people: social workers, nurses, substance abuse counselors, and doctors specializing in obstetrics, pediatrics, and addiction medicine. Every one of them are there to learn how to care for pregnant women using opioids or addicted to opioids.

This actually happened earlier this month at the POEP conference in Greensboro, NC. (POEP stands for Pregnancy & Opioid Exposure Project. You can learn more about this organization at their website: http://www.ncpoep.org )

This organization, funded through a federal block grant through the NC Department of Mental Health, is run by the UNC School of Social Work. The organization has managed to bring together many of the people in our state who take care of pregnant women with opioid addiction. The goal of POEP is to disseminate information, resources, and technical assistance regarding all aspects of opioid exposure in pregnancy. The organization was formed in 2012 in response to concerns about the problem of pregnant women being exposed to opioids.

This organization is talking about all opioid use in pregnancy, not only about addiction in pregnancy. Some pregnancy women are prescribed opioids for the treatment of pain. These women may have physical dependence on opioids, though they may not have the mental obsession and compulsion to take opioids. However, the same problems can be seen in the newborn whatever the reason the woman takes opioids, so there is overlap in the problems faced.

This conference had renowned speakers; Marjorie Meyer, an expert in maternal-fetal medicine from Vermont, was the keynote speaker. This doctor participated in the MOTHER trials, and also set up an innovative treatment method in Vermont for mothers addicted to opioids. She has written about her data, and contributed greatly to our knowledge about buprenorphine in pregnancy (see my blog post of February 28, 2015).

Dr. Hendree Jones, lead author of the MOTHER study, did an excellent session on myths about medication-assisted treatment in pregnancy. She’s also a world-renowned leader in the field of addiction in women.

Dr. Stephen Kandall was there, and spoke about the challenges of advocating for women with addiction, with some historical perspective. He wrote an outstanding book, “Substance and Shadow: Women and Addiction in the United States,” which is one of my all-time favorites. It’s one of the best books about females and addiction. This conference was the first time I met Dr. Kandall, and I got all creepy-gush-y, and dithered about how much I loved his book. I can be such a nerd at times, but he was very polite and gracious.

There were many sessions going on at the same time, so it was impossible to go to all of the sessions that I wanted to attend. Other speakers talked about how best to coordinate care for pregnant women when they go to the hospital to deliver their babies, how to work with the court system if the pregnant woman has legal problems, and how to work with female patients on opioids about family planning.

I was honored to be one of the four-doctor panel that was organized to answer audience questions about medication-assisted treatment with buprenorphine and methadone during pregnancy. We got some great questions, like how to deal with co-occurring benzodiazepine use during pregnancy. Our session was only forty-five minutes long, and we probably could have spent a few hours answering all their questions. I was also impressed by the thoughtful opinions and recommendations from the other three doctors, all leaders in our state.

This conference was a great experience. I felt like many of the attendees got a better view of what opioid-dependent pregnant women need, and where and how to direct them for the best care. I’m pleased people in our state cared enough to start the difficult work of informing families and care providers about the problem of opioid use and addiction during pregnancy.

POEP has a great website that I’ll recommend to the pregnant women I treat, and I’ll also recommend it to their obstetricians. That site has clear information not only for families, but also for care providers. Here are the fourteen important points for infant care providers, taken directly from the POEP website:

“Key Messages for Infant Care Providers Working with Families of an Opioid-Exposed Newborn
________________________________________
1. Parents should be counseled as early as possible (preferably well before delivery) about the need for close monitoring of an opioid-exposed infant.[2]
2. Parents should be encouraged to disclose any maternal opioid use that occurred during pregnancy and should be treated in a nonjudgmental manner.[3]
3. Hospital care of the newborn should be family-centered, meaning that the parents should be a driver in the care plan.
4. Parents should receive education about how opioid-exposed infants are monitored and how neonatal abstinence syndrome (NAS) is treated at their delivery hospital.
5. There are various approaches to monitoring for neonatal abstinence syndrome in opioid-exposed infants, such as the use of the Finnegan Scoring tool.[2],[3]
6. Monitoring for the onset of NAS may mean the infant will be monitored in the hospital for up to 5 days.
7. Infants at risk of NAS may be monitored in the mother’s room, in the newborn nursery, special care nursery or neonatal intensive care, depending on hospital protocols and resources.
8. There are various approaches to the management of NAS including non-pharmacologic interventions and pharmacologic therapy, depending on the needs of the infant. Approaches include:
• Non-pharmacologic management of NAS: environmental controls emphasizing quiet zones, low lighting, and gentle handling. Loose swaddling, as well as holding and slow rocking of infant may be helpful. The use of a pacifier for excessive sucking is also helpful.[2],[6],[7]
• Pharmacologic management of NAS: the use of a variety of medication to ease the withdrawal symptoms of the infant. Common medications include opioids (dilute tincture of opium, morphine, or methadone) and phenobarbital.[2],[6],[7]
9. Breastfeeding is encouraged for women in medication assisted treatment, unless there are medical reasons to avoid it. Reasons to avoid breastfeeding include an HIV infection or specific medication for which breastfeeding is not safe.[2],[3]
10. Infants experiencing NAS may have difficulty establishing breastfeeding or bottle-feeding. Women may need additional encouragement and lactation consultation to support breastfeeding.[2],[3]
11. Whenever possible, having the newborn room-in with the mother while in the hospital is encouraged. Benefits include opportunity to initiate breastfeeding, bonding and decreased need for treatment of NAS.[1]
12. Some infants will experience NAS as a result of maternal opiate use through a treatment program (such as a methadone maintenance program) or by prescription (such as buprenorphine for an opioid use disorder or prescription narcotics for pain management). The opioid exposure alone in situations where the mother was adherent to a prescribed treatment plan would not constitute an appropriate reason for referral to Child Protective Services. See structured intake 1407 http://info.dhhs.state.nc.us/olm/manuals/dss/csm-60/man/
13. Not all infants at risk of NAS are identified in the hospital, particularly in situations where maternal use of opioids has not been disclosed. This may be due to women not disclosing legal or illegal use of opioids.[2]
14. Withdrawal symptoms from opioids may appear in the infant after discharge to home. It is important for providers working with the infant and the family in the community (pediatricians, CC4C, Early Intervention) to be aware of signs and symptoms of NAS. If the infant displays any of these signs or symptoms, the family should be encouraged to seek pediatric care promptly.[2]”

North Carolina has a great start in addressing the problem of opioid-exposed newborns. The organizers of POEP can stand as an example of how other states can begin to address this challenging situation. Neighboring states (you know I’m talking about Tennessee!) have walked in the opposite direction, preferring to view opioid use during pregnancy as a crime rather than the medical problem that it is. That’s sad, because an aggressive attitude of judgment is correlated with poorer outcomes for both mother and infant.

Congratulations to the organizers of the POEP conference. Hopefully it was the first of many more to come.

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2 responses to this post.

  1. Posted by John Cunningham on April 1, 2015 at 8:16 pm

    Hi Jana I was really hoping you could give me some advice. A friend of mine has just given birth to a healthy baby boy 6 days ago and for the first 4 days the baby was seen by 4 different pediatricians and was scoring very low and was supposed to go home on the 5th day as ha was going so well. On the 5th day a new doc came in and decided no he is in wd and needs to be put on morphine 0.5mg and a clonidine dose also as the only thing he was showing when he had no rug a=on he was a bit stiff in the legs and the arms but when he was wrapped up he seemed fine to the mother and to 4 other docs..Of course if my friend said she thought he wasn’t in Wd as he was sleeping well and eating at the right time that they would ring dcf and say she was not treating her baby with care which you know is wrong. What I would really appreciate if you could let me know is it common for a bubto be fine for four days and then start to w/d afte the 5 th day..The doctor was an nti mmt doc as when he spoke to the mum she said he had to whisper Methadone and would not even look her in the eye ..And the other / I would like your advice on is this doc says w.d may not start for 14 days which to me just sounds bizarre..T would so appreciate your advice as I llve reading you blogs an dwould love you as my doc haha have a great day thanx JJohn

    Reply

    • The scientific literature on neonatal abstinence says it can start at day 6 or even day 7. So yes, it is possible your friend’s baby had a late onset of withdrawal.
      Having said that…for some reason, some hospitals in my state keep the babies a very long time compared to other hospitals. I believe there is some overtreatment, misinterpretation of normal things like crying as those of opioid withdrawal.
      In our state, hospitals should use the Finnegan or modified Finnegan scale as a way to quantify severity of babys’ withdrawal. One borderline withdrawal score isn’t usually the basis for starting opioid treatment in the baby. And yes, often simple things like swaddling, breast feeding, keeping the room dark and quiet helps withdrawal.
      If I were the mom, I’d ask for another doctor to see my baby, maybe one with experience in this area.

      Reply

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