The tiniest victims of the opioid crisis are the babies born with neonatal abstinence syndrome (NAS), and, specifically, neonatal opioid withdrawal syndrome (NOWS).
Overall in the US, the number of babies born with NAS is considered to be 6.7 per 1,000. However, those numbers increase based on different factors: American Indian/Alaska Natives have babies with NAS in 1.5 of 100 births. Babies born to those with the lowest income have NAS closer to 1 per 100 births, as do those born in the Northeast, those born to non-Hispanic white individuals, and those born in rural areas. Pretty much babies born to people with financial means in cities have a better chance of not having NAS, so the stats show.
But where focus goes, energy flows. We really don’t know if the statistics are accurate because testing of neonates for opioids – or any other mood-altering substance for that matter – isn’t happening across the board. But what if it were?
The American Society of Addiction Medicine (ASAM) prepared a document, “Appropriate Use of Drug Testing in Clinical Addiction Medicine,” to “provide guidance about the effective use of drug testing in the identification, diagnosis, treatment, and promotion of recovery for patients with, or at risk for, addiction.” (Jarvis, et al)
As I’ve stated before in these blog posts, if we truly believe that addiction is a chronic, progressive, lethal disease, we need to diagnose and treat it accordingly. That means that drug testing should never be a “gotcha.” It should be a tool to ensure that people, in this case, babies and the pregnant parent, have a chance at the best possible outcomes. ASAM agrees.
The ASAM document indicates that testing may be a part of obstetrical best practice, but there are protocols to follow to make it so, specifically consent and conveying the therapeutic reasons for drug testing to avoid stigmatization. ASAM indicates that “In a prenatal care setting, routine Screening and Brief Intervention for alcohol use should be conducted (emphasis is mine), but laboratory testing is not recommended except in cases of suspected or known risk factors (again, emphasis is mine) for Alcohol Use Disorder. As pregnant [people] who use substances are less willing to disclose the use of opioids and benzodiazepines than other substances, testing for opioids and benzodiazepines helps identify an often underreported behavior.” (http://eguideline.guidelinecentral.com/i/840070-drug-testing-pocket-guide/0?)
A 2020 study by England, Bennett, and Denny estimated that 40% of those who were pregnant and used alcohol self-reported using other substances. (England, et al) However, I recently had cause to review umbilical cord specimens received for routine analysis by United States Drug Testing Laboratories (USDTL) in Des Plaines, Illinois, between January 2019 and December 2021. My review provides evidence that those who were pregnant and used alcohol are polysubstance users 58% of the time, putting neonates at greater risk – nearly 20% greater risk – than previously estimated!
We’re seeing that a full 58% of alcohol users who use alcohol while pregnant are polysubstance users, and umbilical cord testing is helping to bring that information to light where it can be fully addressed and mitigated for both parent and baby.
Umbilical cord testing can be a best practice solution: if umbilical cord tissue were taken from each and every neonate as a course of protocol, there would be no stigmatization, no discrimination, and no expectation. If a hospital system says, “Our policy is to take a portion of umbilical cord tissue from EVERY neonate,” all other concerns are dismissed. What the hospital gets, though, is a spectacular amount of intervention potential in that tissue.
Umbilical cord tissue is easy to gather – much easier than other substances – and the likelihood of not having enough of the sample is much lower than it is for meconium or neonate urine or hair. Umbilical cord tissue is easily stored for later testing, which makes it a supremely valuable matrix for testing. Gathering it on every birth ensures that if there are concerns about NAS, there’s a sample available to test.
Most new births won’t need testing: baby shows no signs of withdrawal, gets discharged, and follow up occurs as expected. But what about for those babies who do show signs of withdrawal, especially if those signs weren’t immediate? With a blanket protocol to gather umbilical cord, no opportunity was missed because the tissue sample is available, having been easily gathered and stored since birth.
Gathering umbilical cord tissue at every birth is likely to reduce the cost of neonates treated for NAS because hospitals will know more quickly what is wrong, which goes far in treating it more quickly, thereby reducing the days of hospital stay and the cost of treatment for babies with NAS and NOWS. Umbilical cord testing combined with a relatively new approach to assessment and treatment of NAS/NOWS, “Eat, Sleep, Console” (ESC), which was developed by Yale University School of Medicine, Boston University School of Medicine, and Children’s Hospital at Dartmouth, leads to better parent interaction; fewer days of hospitalization, particularly NICU; less use of morphine to treat babies; and lower costs of care. (Grossman, et al)
Umbilical cord testing is a surefire way to do better to help the tiniest victims of the addiction crisis in the US. If 1% of babies were suffering the consequences of any other disease carried by parents, we’d already have sounded the alarm! Let’s start treating addiction as the chronic, progressive, lethal disease it is and providing patient education, referral to treatment, and creation of a treatment plan.
References
England LJ, Bennett C, Denny CH, Honein MA, Gilboa SM, Kim SY, Guy GP Jr, Tran EL, Rose CE, Bohm MK, Boyle CA. Alcohol Use and Co-Use of Other Substances Among Pregnant Females Aged 12-44 Years – United States, 2015-2018. MMWR Morb Mortal Wkly Rep. 2020 Aug 7;69(31):1009-1014. doi: 10.15585/mmwr.mm6931a1. Erratum in: MMWR Morb Mortal Wkly Rep. 2020 Aug 28;69(34):1184. PMID: 32759915; PMCID: PMC7454897.
Grossman, Matthew R., Lipshaw, Matthew J., Osborn, Rachel R., Berkwitt, Adam K.; A Novel Approach to Assessing Infants With Neonatal Abstinence Syndrome. Hosp Pediatr January 2018; 8 (1): 1–6. https://doi.org/10.1542/hpeds.2017-0128 See the instruction manual here: (Chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cffutures.org/files/QIC_Resources/Learning_with_the_Expert/Eat_Sleep_console_manual_with_tools_Yale_Boston_NNEPQIN.pdf)
Jarvis, Margaret MD, DFASAM; Williams, Jessica MPH; Hurford, Matthew MD; Lindsay, Dawn PhD; Lincoln, Piper MS; Giles, Leila BS; Luongo, Peter PhD; Safarian, Taleen BA. Appropriate Use of Drug Testing in Clinical Addiction Medicine. Journal of Addiction Medicine 11(3):p 163-173, May/June 2017. | DOI: 10.1097/ADM.0000000000000323 (https://journals.lww.com/journaladdictionmedicine/Fulltext/2017/06000/Appropriate_Use_of_Drug_Testing_in_Clinical.1.aspx)
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