Lessons from the Front Lines of the Neonatal Abstinence Syndrome (NAS) Epidemic
An Interview with Neonatal Nurse Practitioner Carla Saunders, Knoxville, Tennessee
Carla Saunders has been working as a Neonatal Nurse Practitioner with newborns in intensive care for 24 years. As early as 2008, Saunders and her colleagues at the East Tennessee Children’s Hospital started to see a steady increase in newborn infants with Neonatal Abstinence Syndrome (NAS)—born dependent on opioids, and going through withdrawal. Even as the number of NAS babies rose from 35 to more than 250 a year in her hospital, Saunders organized a task force to develop urgently needed treatment protocols that would safely wean the newborns off opioids. Their team has treated 1,000 newborns for NAS in the first 4 years of the program. COPE talked with Saunders about her work with NAS babies, and the origins of the Neonatal Abstinence Syndrome crisis.
Q: What causes Neonatal Abstinence Syndrome (NAS)?
What a mother uses the baby is exposed to. When an opioid-exposed baby is born and the umbilical cord is cut, so is their drug supply. The baby may begin to experience physiologic withdrawal.
A very small percentage of babies will show withdrawal symptoms in the first minutes or hours of life and this can be in the form of seizure. For most babies, onset of withdrawal occurs within 3 to 5 days of life but may be delayed as long as 10 days.
This is the second year that NAS has been reportable to the Tennessee Department of Health. They are finding that 60 percent or more of mothers with NAS babies were taking prescribed narcotics during pregnancy, either an opioid-based pain medication or medical replacement therapy for opioid addiction such as methadone.
Q: How does NAS affect newborns?
NAS babies have a very specific high-pitched shrill cry. I could blindfold a nurse who takes care of these babies, take her to the nursery, and she could tell you which crying baby is in withdrawal.
Babies with NAS can be very irritable, tight, tremulous, run fevers, have rapid breathing, excessive but ineffective sucking, feeding intolerance, cramping, diarrhea, dehydration, poor weight gain, skin breakdown, sweating, sneezing, and seizures.
They can have difficulty feeding. Even with a nipple in their mouth, they will root and thrash, but they can’t organize their brain to latch onto the nipple and suck. And when they do, their suck is often ineffective. Sometimes we must tube feed babies until we gain control of their symptoms.
They can have vomiting and diarrhea. Their bottoms can look scalded. We use specialized diets for digestion, and skin barriers to protect their skin and prevent breakdown and bleeding of fragile tissues. Sometimes they are so tense—their hips are so tight—that it can be difficult to change their diapers.
Q: How do you treat NAS?
The first line of treatment is comfort care, behavioral and environmental measures to prevent or decrease the amount of medication needed. According to the American Academy of Pediatrics, treatment choices are Oral Morphine, or methadone. We chose tiny doses of oral morphine dose based on the severity of symptoms. After we have 48 hours of stability, we wean them by 10% a day.
The first year of the program, the average length stay was 34 days. Through intense study we have reduced it to 22 days. On average, it costs three times as much to care for an NAS baby as it does a preterm baby. NAS is 100% preventable. If a baby is not exposed in utero, it will not experience NAS.
Q: Is the prescription opioid epidemic a women’s health issue?
It is a national issue and a women’s health issue. Substance abuse is the number one cause of accidental death in the United States, exceeding motor vehicle accidents.
According to the CDC, opioid use is the number one cause of overdose deaths, and women of childbearing age are the fastest growing demographic within that population.
It is easy for people to fall into a prescription drug problem. We believe it is safe because it is prescribed. People who would never even drink or cross over into illegal drugs can find themselves dependent on prescription narcotics. An individual can develop tolerance, needing more medication to receive the same effect. Physical dependence can develop in a matter of weeks—meaning that once you stop taking it, you feel sick. In an attempt to avoid feeling sick, people continue to use and soon find themselves in a state of addiction where they will do anything to either not feel sick or to seek the high.
Q: How big a problem is NAS?
A JAMA article (2012) reported that at least one infant an hour was being born with NAS in the United States in 2009—and its incidence has grown rapidly since then.
Approximately 80% of women prescribed a narcotic in Tennessee do not have a prescription for a long-acting reversible contraceptive. We know that among opioid-dependent women, 80-90% of pregnancies are unintended. Furthermore, women are not routinely informed about the risks of prescription opioids to the unborn child or potential long-term effects.
Q: How did we get to this point?
The origins of the prescription opioid epidemic go back to the late ‘80s, when the Veterans Administration determined that pain was undertreated. At that point, opioids were reserved for end-of-life treatment. They were considered highly addictive. There were limits on who could prescribe and how much.
In the 1990s there was a movement to declare “Pain as the Fifth Vital Sign.” A few small studies on “long-term” opioid use (that lasted not more than two to three weeks) suggested risk of addiction was minimal. The previous restrictions were lifted and penalties were placed for providers and hospitals who were not adequately assessing and treating pain. Soon there was a cascade of prescribing, and pharma responded with more potent and longer-acting narcotics.
Q: What is the role of provider education in ending this epidemic?
The onus is on medical providers to end the prescription opioid epidemic because we are so trusted. We need to educate ourselves, and our patients, about the science of addiction and to practice responsible prescribing. We need to make substance abuse training part of wellness screening, just as we did for HIV and hepatitis. This begins to take the stigma out of it. We need to conduct risk assessments with our patients as part of routine well care and we need to check controlled substance monitoring databases prior to prescribing narcotics to identify potential problems early on. We need to talk about pregnancy prevention for women of childbearing age who are on these medications.