Page 15 - Delaware Medical Journal - April 2016

PUBLIC HEALTH
IntroductionMore persons died from characterized by compulsive drug seeking and use, despite
drug overdoses in the United States in 2014 than during any previous year on record, with
approximately one and a half times as many deaths than in motor vehicle crashes.1 Drug use in the United States (US), including
in pregnant women, is rising – 4.4 percent of pregnant women use illicit drugs, with a much higher rate in women aged 15 to
25 years. Approximately 180,000 infants annually are born with neonatal abstinence syndrome (NAS)2 which can directly affect infant development. Many of these infants require prolonged hospitalizations and require multifaceted inter-professional skills to guide them and their mothers through the period of withdrawal. Although there are no formal statewide data on NAS in Delaware, the number of infants with the NAS diagnosis has increased from 105 in 2010 to 173 in 2014 at Christiana Care Health System with a concomitant increase in patient days from 1,445 to 3,102 per year.
The American Congress of Obstetricians and Gynecologists (ACOG) states that there are multifactorial reasons for drug use, which
is a biologic and behavioral problem with genetic components.3 Substance abuse affects more people who are living in poverty, who have experienced abuse or trauma, and who are unemployed, or
have mental illness. This means that a large percentage of women who deliver opiate exposed infants are uninsured or on Medicaid.
In some population-based studies as many as 70 percent or more
of infants diagnoses with NAS are on Medicaid.4 By one estimate Medicaid will pay one trillion dollars for substance abuse over the next 20 years.5 This translates into problems for families, health care systems, legal systems, and society.
Caring for patients with NAS requires empathy, knowledge, and curiosity. It demands experience and stamina. Due to increased numbers of opiate exposed mother-infant dyads, the stress and challenge of caring for vulnerable families is only increasing. The caregiver, mother, and infant are in a continual feedback loop with the actions of each affecting the reactions of the other.6,7 Care of the opioid addicted mother is not emphasized in most medical training. It is a specialty area of its own. Nonjudgmental communication that balances needed supports and limits to the actively addicted
or recovering is not in most medical professionals’ toolbox.8 Professionals need to expand knowledge and understanding of the addiction process and the evidence based interventions that best serve mothers and infants.
BACKGROUND

harmful consequences.”9 Addiction is a disease of both brain and behavior, and science has yet to understand the various reasons why people use drugs or how drugs affect the brain to compel addiction.9 The national increase in NAS has
been linked to prescription drug use.4 Recent Delaware data shows alarming statistics that the top 1 percent of prescribers wrote one in four opioid prescriptions in Delaware. The top 10 percent of prescribers in Delaware wrote two thirds of all opioid prescriptions and wrote for the highest daily dosage among all states.1

for these vulnerable, sick infants whose issues stem directly
from maternal actions. Most nurses and physicians are not trained in addiction behaviors and the life experiences of those with addiction.10,11 This absence of training may impede the relationships, and in turn accentuate negative feelings held by the mother. The lack of a trusting relationship can mean a mother is four times less likely to receive adequate preventive and ongoing health care. This may include how to bond with her infant.9
Caregivers without an understanding of the addiction experience may reinforce negative behavior such as non- visitation on the part of the mother.6,7 Additionally, a paucity of maternal education on the topic of infant cues and signs of withdrawal exhibited by the infant may perpetuate maternal actions that exacerbate infant distress.12
CURRENT TRENDS
There is a growing movement nationally to enact punitive approaches to the opioid addicted mother. This may be driven not by evidence, but by a perceived need to intervene in the abuse cycle. Nurses are increasingly raising their voices against the mother, advocating for foster care13
for the mother. These ideas seem born of frustration rather
than evidence. Evidence suggests that mothers and infants
kept together have improved outcomes.14,15 Indeed, the New Expectations program under the Delaware Department of Corrections is an example of a novel program working to keep mothers and infants together while searching for solutions which break the cycle of incarceration. Studies have also pointed out that mandatory reporting systems create fear of incarceration, fear of removal of the infant from parental care, or require entry into the social service system. Additionally, mandatory reporting can interfere with patient provider relationships.16 The American
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