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    ONDCP paying attention to prenatal exposure to opioids

    The nation's drug czar's office highlighted the issues around the increased use of opioids by pregnant women at a recent meeting, held just across from the White House.

    "We do know that there is an increase in use of opiates among women of childbearing age. We don't get as much information as we would like regarding the prevalence and the long-term effects of prenatal exposure to opioids," said Gil Kerlikowske, director of the Office of National Drug Control Policy (ONDCP).

    As with other drug-abuse problems, there are many gaps in the research, and studies are not always as relevant or as timely as wanted, he said at the August meeting, which he said was his office's effort to gather the best minds on the issue to help determine a response.

    Kerlikowske stressed that the ONDCP strongly supports family-based treatment, noting that women with substance-abuse problems often will not go into treatment because they have no one to care for their children.

    Key speaker Hendrée Jones, PhD, senior research psychologist with Research Triangle Institute International, noted that the number of pregnant women who use opioids is still only a fraction of those who smoke or drink alcohol, according to Substance Abuse and Mental Health Services Administration data for 2009-2010.

    She called neonatal abstinence syndrome (NAS), or the withdrawal newborns suffer when no longer exposed to the opioids, an expected and treatable condition, saying, "Neither NAS nor its treatment is known to produce compromised developmental outcomes."

    Jones noted that opioid use in pregnancy often occurs in the context of other adverse circumstances for mother and child, including exposure to violence and trauma, psychiatric problems, and lack of formal education and job acquisition and maintenance skills. She asserted that prevention and treatment of opioid addiction in pregnant women would require multifaceted interventions.

    Stephen Patrick, MD, MPH, of the University of Michigan Health System, pointed to data showing that in 2009 almost 31% of newborns with NAS had respiratory diagnoses compared with 8.9% of all hospital births. In addition, low birth weight comprised 19.1% of babies with NAS compared with 7.0% for other hospital births. Seizure levels are 2.3% in babies with NAS compared with 0.1% of other babies, according to the analysis.

    He also pointed out that hospital charges for NAS almost quadrupled from 2000 to 2009, from $190 million to $720 million. The challenge for states, he noted, is that about 80% of infants with NAS are enrolled in Medicaid, which is a huge part of state budgets.

    Karol Kaltenbach, PhD, director of Maternal Addiction Treatment Education and Research at Thomas Jefferson University in Philadelphia, said, "There is significant variability in hospital policies and practices that determine both the diagnosis and treatment of NAS."

    Saying there's a need to talk about the medications used for NAS treatment, she said most hospitals use morphine, which she indicated is very effective, and new research on buprenorphine also indicates it is effective. There is no data on methadone's effectiveness, which many hospitals are using.

    Breastfeeding is an important factor because little of the opioid passes into the breast milk, Kaltenbach said, indicating that the nurturing interaction alleviates many of the symptoms. Having to go to the neonatal intensive care unit exacerbates presentations of NAS, but when mothers care for their infants in rooming-in situations, those issues are reduced.

    After the meeting, Kerlikowske said that the next steps have not been hammered out, given that the meeting was the first time some of the researchers and others were in the same room. He said his office would be looking at the information gathered and possibly talking to people in Congress.

    Kathryn Foxhall
    MS. FOXHALL is a contributing editor for Contemporary Pediatrics.

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