Maternal Drug Use and Its Effect on Neonates

Abstract & Commentary

By Rebecca H. Allen, MD, MPH, Assistant Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI, is Associate Editor for OB/GYN Clinical Alert.

Dr. Allen reports no financial relationships relevant to this field of study.

Synopsis: This study from Washington State reports that prenatal drug exposure and neonatal abstinence syndrome rates increased from 2000 to 2008, leading to longer hospitalizations for affected neonates and increased perinatal complications.

Source: Creanga AA, et al. Maternal drug use and its effect on neonates: A population-based study in Washington state. Obstet Gynecol 2012;119:924-933.

The authors sought to estimate trends in prenatal drug exposure and neonatal abstinence syndrome (NAS) in Washington State from 2000 to 2008. They also identified the types of drugs used, predictors of prenatal drug use and NAS, and outcomes of drug-exposed and NAS-diagnosed neonates. The investigators utilized the Birth Events Record Database maintained by the Washington State Department of Health, which links birth certificate data to mother and infant hospital discharge data that have been validated. To identify prenatal drug exposure and NAS, International Classification of Diseases, 9th Revision, Clinical Modification multiple (ICD-9-CM) codes related to drug use in the mother and infant were used to search the records. Due to limitations in ICD-9-CM codes, the authors were unable to differentiate between illicit and prescription drug use. Drug exposure was categorized into four categories: 1) opioids and related narcotics; 2) cocaine; 3) other psychotropic drugs (including sedatives, hypnotics, and tranquilizers); and 4) other or unspecified drugs.

Between 2000 and 2008, 669,451 medical records had complete data for evaluation. Using ICD-9-CM codes, 9,024 (1.3%) drug-exposed neonates were found. Of these, 18.9% were diagnosed with NAS. Drug exposure rates increased from 10.6 per 1,000 births in 2000, peaked at 16.3 per 1,000 births in 2005, and were 14.3 per 1,000 births in 2008. Similarly, NAS rates increased from 1.2 per 1,000 births in 2000 to 3.3 per 1,000 births in 2008. In 2008, the majority of prenatal drug exposures (41.9%) were to psychotropic drugs, followed by 24.4% to opioids, and 10.5% to cocaine. The proportion of NAS among neonates exposed exclusively to opioids increased from 26.4% in 2000 to 41.7% in 2008 (P < 0.05).

Risk factors for prenatal drug exposure included neonates born to Native American or Alaska native women (adjusted odds ratio [OR]. 1.8; 95% confidence interval [CI] 1.7-1.9), being unmarried (adjusted OR 1.8; CI 1.5-2.2), having a diagnosis of a mental health disorder (adjusted OR 3.7; CI 3.4-4.0), and no prenatal care (adjusted OR 11.0; CI 10.0-12.0). Protective factors were having more than 12 years of education (adjusted OR 0.6; CI 0.6-0.7) and private insurance (adjusted OR 0.3; CI 0.3-0.3). These associations also were significant for the diagnosis of NAS. In addition, the older the age of the woman and the more children she had, the more likely it was that the neonate was exposed to drugs prenatally or was diagnosed with NAS.

The mean length of birth hospitalization was 2.6 ± 6.3 days for unexposed neonates compared to 6.5 ± 12 days (P < 0.001) for drug-exposed neonates and 14.4 ± 14.3 days (P < 0.001) for neonates diagnosed with NAS. Newborns exposed to drugs had 2.6 to 3.4 times and newborns diagnosed with NAS had 4.1 to 9.2 times the odds of being born preterm, with low birth weight, having feeding problems, respiratory distress syndrome, or other respiratory conditions compared to unexposed newborns. After adjusting for prematurity and low birth weight, the odds ratios for these perinatal outcomes declined but were still significant.

Commentary

Most commonly associated with prenatal opiate use, NAS is a drug withdrawal syndrome in newborns following birth. NAS is characterized by increased irritability, hypertonia, tremors, feeding intolerance, emesis, watery stools, seizures, and respiratory distress.1 The fact that prenatal drug exposure and NAS in the United States has increased in recent years has been well-documented in the medical literature and national press.2,3 Although this study is somewhat limited by its reliance on ICD-9-CM codes for case identification,4 the authors mention other research that documents a rise in opioid-exposed newborns in Washington State. A national study with similar methods recently found a substantial increase in maternal opiate use between 2000 and 2009, from 1.19 per 1,000 births per year to 5.63 per 1,000 births per year as well as an increase in NAS from 1.2 per 1,000 births per year to 3.4 per 1,000 births per year.2 Therefore, the problem is not limited to Washington State.

The American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine recommend that all pregnant women be screened for substance abuse including alcohol, illicit drugs, and prescription drugs.1 The use and abuse of prescription opioid medication has become more common in the United States.1 In addition, in certain areas of the country, methamphetamine abuse is a concern.5 Identifying substance abuse in pregnancy allows the prenatal provider to refer women for treatment and manage the pregnancy accordingly. Each state has different reporting requirements concerning substance abuse during pregnancy. Fourteen states require health care professionals to report suspected prenatal drug abuse and four states require them to test for prenatal drug exposure if they suspect abuse.6 These reports can then be used as evidence in child-welfare proceedings. Fifteen states consider substance abuse during pregnancy to be child abuse under civil child-welfare statutes. Unfortunately, these requirements disrupt the relationship between the woman and her provider, and often deter women from disclosing substance abuse and even seeking prenatal care.7 This is regrettable because both the treatment of opioid addiction in pregnancy and prenatal care has many benefits. Treatment with methadone or buprenorphine in pregnancy prevents complications of illicit opioid use and narcotic withdrawal as well as reduces the risk of obstetric complications.1 NAS is an expected outcome of this treatment and is treated in collaboration with the pediatric team.

The trend toward the criminalization of substance abuse during pregnancy is alarming.3,8 Depending on the state, women may face incarceration, involuntary commitment, loss of custody of her children, and loss of housing.7 We have all seen women suffer from these policies. It is not surprising that harsh drug enforcement policies may dissuade women from seeking prenatal care or may even promote pregnancy termination to avoid prosecution.3 Addiction should be managed as a disease, not as negligent or criminal behavior.7 Furthermore, certain states mandate reporting of substance abuse in pregnancy and consider such behavior child abuse but do not have any drug treatment programs specifically targeted to pregnant women nor give pregnant women priority access to state-funded drug treatment programs.6 Thus, even women who desire substance abuse treatment in pregnancy may not be able to find it. It is more appropriate that states work with prenatal care providers and addiction specialists to promote positive legislation to help women with substance abuse issues.7

References

  1. The American College of Obstetricians and Gynecologists. The American Society of Addiction Medicine. Committee opinion no. 524: Opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol2012;119:1070-1076.
  2. Patrick SW, et al. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA 2012;307:1934-1940.
  3. Calhoun A. The criminalization of bad mothers. The New York Times Magazine April 25, 2012.
  4. Grimes DA. Epidemiologic research using administrative databases: Garbage in, garbage out. Obstet Gynecol 2010;116:1018-9.
  5. Committee Opinion No. 479: Methamphetamine abuse in women of reproductive age. Obstet Gynecol 2011;117:751-755.
  6. Guttmacher Institute. Substance abuse during pregnancy. State Policies in Brief. Available at: www.guttmacher.org/statecenter/spibs/spib_SADP.pdf. Accessed May 18, 2012.
  7. AGOG Committee Opinion No. 473: Substance abuse reporting and pregnancy: the role of the obstetrician-gynecologist. Obstet Gynecol 2011;117:200-201.
  8. Figdor E, Kaeser L. Concerns mount over punitive approaches to substance abuse among pregnant women. Guttmacher Report on Public Policy1998;1:3-5.