Women who are addicted to opiates and their children are cared for
The impact of the opioid epidemic on moms and their children.
Most Americans are now aware of the deadly opioid epidemic in the United States. Drug overdose deaths in the United States have continued to rise among men and women of all races and ages, with opiates accounting for two-thirds of all drug overdose deaths in 2017 (Hedegaar, Minio, & Warner, 2018). The rising death toll from opiate abuse has triggered a crisis in child welfare, with nearly 429,000 children entering care between 2013 and 2015 (U.S. Department of Health and Human Services Administration on Children and Families), and children in care whose parents have not died from an overdose but do actively use/abuse substances have worse outcomes than other foster children (Lloyd & Akin, 2014). (Brook, McDonald, Gregoire, Press, & Hindman, 2010).
As more resources are put into combating the opioid epidemic, which mostly relies on Medication Assisted Treatment (MAT; e.g., methadone and buprenorphine), psychologists are being asked to become more knowledgeable about addiction medicine and behavioral therapies for this group. Child psychologists working in hospitals, particularly those in the NICU or nursery wards, can serve an important role at the crossroads of child welfare and medicine. The purpose of this article is to (a) familiarize the reader with best practices for pregnant and postpartum women with opiate use disorders; (b) educate psychologists about the medical management of these women and their prenatally exposed infants; and (c) make recommendations for the opiate-dependent/opiate-exposed mother-infant dyad's ongoing integrated care.
For many women, learning of a pregnancy can be a life-changing event, and it is sometimes enough to drive opiate-dependent women to seek treatment for their addiction. Many women, in our experience, would switch to Medication Assisted Treatment (MAT) after learning of their pregnancy with the help of their doctor. Methadone and buprenorphine keep the body from going into withdrawal while also limiting the euphoria that comes with opiate use. Because withdrawal and detoxification procedures entail a greater dropout and relapse rate, MAT is the most scientifically approved treatment regimen for opioid addiction during pregnancy (Brook et al., 2010).
Despite a history of opiate use/abuse early in pregnancy, some women may be concerned about starting MAT with a synthetic opiate (rather than pursuing total detoxification) for fear of harming the growing fetus. In reality, Jones, Jansson, O'Grady, & Kaltenbach (2013) found no link between monitored synthetic opioid usage and birth deformities or the severity of withdrawal for the newborn after birth (Jones, Dengler, Garrison, O'Grady, Seashore, Horton, Andringa, Jansson, & Thorp, 2014).
Although there is no link between the amount of maternal opioids used and the severity of withdrawal symptoms experienced by the infant after birth, there are other risks associated with illicit opiate use during pregnancy, including placental abruption, preterm labor (Almario, Seligman, Dysart, Berghella, & Baxter, 2009; Cleary, Donnelly, Strawbridge, Gallagher, Fahey, White, & Murphy, 2011), abnormal heart patterns, low birth weight, and small (Hulse, Milne, English, & Holman, 1997; Madden, Chappel, Zuspan, Gumpel, Mejia, & Davis, 1977). As a result, when combined with comprehensive obstetrical care and behavioral intervention to support maternal efforts toward harm reduction, MAT is most successful.
Infants exposed to opiates before birth are at risk for Neonatal Abstinence Syndrome (NAS), a complicated illness involving the central and autonomic nerve systems, as well as the gastrointestinal system, that is generally referred to as "withdrawal." Irritability, fever, diarrhea, vomiting, poor eating, sleep disturbances, seizures, and frequent sneezing are all symptoms of NAS. The frequency of NAS varies, although it is currently thought to occur in around half of all newborns exposed to buprenorphine and/or methadone (Klamen, Isaacs, Leopold, Perpich, Hayashi, Vender, Compopiano, & Jones, 2017).
Following the delivery of opiate-exposed newborns, the immediate goal is to improve their growth and development while avoiding or limiting undesirable consequences like discomfort and seizures by cautious measures and medication. The onset of NAS is normally within 24 to 72 hours, but it can occur up to four to five days after delivery, prompting the suggestion that all opiate-exposed infants be admitted to the hospital for observation for five to seven days after delivery (Hudak & Tan, 2012).
For the NAS, conservative measures have been proposed. In all opioid-exposed newborns, conservative therapeutic methods such as the 5 Ss (swaddling, shushing, swaying, stomach, sucking) and reducing sensory stimulation should be implemented (e.g., dimming the lights; Abrahams, MacKay-Dunn, Nevmerjitskaia, MacRae, Payne, & Hodgson, 2010).
Breastfeeding has been demonstrated to lower the frequency and severity of NAS, as well as the length of time spent in the hospital (Wachman, Hayes, Brown, Paul, Harvey-Wilkes, Terrin, Huggins, Aranda, & Davis, 2013). It's likely that the very low levels of opioids in breastmilk aid in reducing the severity of NAS (Malpas & Darlow, 1999). Breastfeeding has also been proposed to reduce the severity of withdrawal (WHO, 2014), probably because of the skin-to-skin contact and consequent connection with the mother. As a result, moms who are stable on opiate replacement treatment should be encouraged to breastfeed. If the kid is in care and the court is unaware of the risks of breastfeeding while the mother is on MAT, psychologists and physicians must be prepared to advocate on her behalf.
Pharmacology for the treatment of NAS. MAT can be started with infants who are displaying severe NAS symptoms. There is currently no standardized dose or weaning protocol. The two most widely utilized drugs are morphine and methadone, with morphine being more popular than methadone. Morphine is started in the hospital, and the baby must stay there until he or she is completely weaned. Methadone is started in the hospital, but when the medication is tapered off, the infant may be discharged home. The medicine of choice is determined by the institution, and no studies have demonstrated that one medication is more effective than the other. Kocherlakota (Kocherlakota, 2014)
Dyadic Long-Term Care
Screening for Postpartum Mood Disorders. During the first six months, once the newborn has stopped showing indications of NAS and/or has been effectively weaned off any medication (methadone, morphine), he or she should be visited by the pediatrician at a somewhat higher frequency than low-risk infants. It is critical that physicians and/or psychologists check for postpartum depression and/or anxiety during these primary care pediatric appointments. Feske, Tarter, Kirisci, & Pilkonis (2006) found that opiate-dependent women are more likely to have a coexisting mental disorder such as depression, anxiety, bipolar disorder, posttraumatic stress disorder, or personality disorders (Feske, Tarter, Kirisci, & Pilkonis, 2006; Peles, Schreiber, Naumovsky, & Adelson, 2007; Tuten, Heil, O'Grady, Fitzsimons, This increased frequency of contact not only allows for better monitoring of the infant and mother, but it also aids in the establishment of a stronger bond between the mother and the main care provider/psychologist, which is critical for ongoing substance use/relapse assessment.
Advocacy. When opiate-exposed infants are placed in care, judges are often unaware of the long-term neurological consequences, such as increased irritability and tremors, that can emerge throughout infancy. These neurological symptoms should not be mistaken with NAS because they are long-term effects of prenatal chemical exposure rather than withdrawal symptoms. If the court-ordered visitation arrangement is likely to cause the infant more stress, psychologists working with this population should be prepared to advocate for changes (i.e., visits in noisy, brightly-lit, and crowded places).
Monitoring the progress of the child. Prenatally opiate-exposed children, contrary to popular belief, have average general intelligence (Cubas & Field, 1993; Hans, 1989; Rosen & Johnson, 1985), and while they do score lower on executive functioning tasks than children who have never been exposed, both groups (opiate-exposed and non-exposed) had mean scores in the average range (Konjenenberg & Elinder, 2015). In general, children who have been exposed to opiates are at a higher risk than children who have not been exposed to opiates, although they are similar to other high-risk populations, such as premature babies. We conduct developmental screening at 1, 3, 6, 9, and 12 months in our clinic, as well as developmental testing if problems emerge.
Interventions for parents. Many women who keep custody of their kid while taking MAT for opiate addiction are first-time parents or custodial parents, and they will need assistance and psychoeducation about infant and child development, acceptable disciplinary tactics, and attachment. PC-CARE (Timmer, Hawk, Forte, Boys, & Urquiza, 2018) is a promising practice that is brief enough for a primary care setting. Additional consideration should be given to the role of attachment and the unique way opiate use can influence attachment, bonding, and parenting style throughout the lifespan (Mirick & Steenrod, 2016).
Hundreds of thousands of children have been harmed by the opioid epidemic, including kids born to opiate-dependent mothers. These infants and their caregivers—whether biological, kin, or foster—can proceed through the vulnerable perinatal period with the help of psychologists in the primary care setting, developing safe bonds and increasing the likelihood of keeping on a healthy developmental trajectory. Women on opiate agonist medications like methadone or buprenorphine don't have to feel guilty or humiliated, and they can be empowered to retain their stability as they take on the role of parent.