An Epidemic of Neonatal Abstinence Syndrome

Laura A. Stokowski, RN, MS


March 04, 2015


Substance abuse in pregnancy is by no means a new problem, but the commonly used substances do change from time to time. The latest culprit is opioid pain relievers. Nationwide trends in opioid abuse or dependence during pregnancy show an increasing prevalence from 0.17% in 1998 to 0.39% in 2011, an increase of 127%.[1]

The negative outcomes from opioid use in pregnancy are not limited to effects on the fetus and newborn. Opioid abuse or dependence in pregnancy is associated with increased odds of maternal death, cardiac arrest, intrauterine growth restriction, placental abruption, preterm labor, stillbirth, premature rupture of membranes, cesarean delivery, oligohydramnios, need for transfusion, and length of hospital stay longer than 7 days.[2]

Although this article is geared toward the newborn's caregivers, the mother of the baby inevitably becomes a patient as well. The author touches on the importance of mother-infant attachment, the need to support parenting skills, and the ongoing influence of the home environment on neonatal outcomes. However, issues of tremendous importance, such as whether the mother is enrolled in addiction treatment, whether maternal drug use is continuing (which has an impact on breastfeeding), and the legal implications of prenatal drug use and neonatal harm are not addressed.

The laws of each state determine whether a newborn with NAS can be discharged with the mother who knowingly exposed the unborn baby to harmful drugs, or whether the mother can be charged with a crime for this action. Although most policies are aimed at keeping mother and baby together and emphasize treatment for these women, many mothers fear that their babies will be taken away from them. To counsel and support these mothers, nurses must understand state laws that have consequences for the mother and infant.

Tennessee is one of many states experiencing an epidemic of maternal drug use (42% of which constitutes opioid painkillers) and NAS. From 2000 to 2009, the incidence of NAS in Tennessee increased from 0.7 to 5.1 per 1000 births, exceeding the national average.[1] The problem subsequently worsened. A statewide mandatory reporting system for NAS implemented in Tennessee in 2013 revealed a high rate of NAS cases throughout the state (11.6 per 1000 live births), demonstrating a 16-fold increase since the year 2000.[1]

Although most healthcare professionals, organizations, and policymakers advocate treatment for the mother, the magnitude of the problem has prompted other legislative solutions. In 2014, Tennessee became the first state to criminalize drug use by a pregnant woman if it results in harm to the baby. This law created confusion among healthcare providers because it apparently conflicts with the state's Safe Harbor Act, a law that says that if addicted mothers seek help, the Tennessee Department of Children's Services cannot take their children into state custody on the basis of addiction alone.

A recent Guttmacher policy brief[3] summarized other state policies related to drug use in pregnancy:

Tennessee is the only state that allows assault charges to be filed against a pregnant woman who uses certain substances.

Eighteen states consider substance abuse during pregnancy to be child abuse under civil child-welfare statutes, and three consider it grounds for civil commitment.

Fifteen states require healthcare professionals to report suspected prenatal drug abuse, and four states require them to test for prenatal drug exposure if they suspect abuse.

Nineteen states have either created or funded drug treatment programs specifically targeted to pregnant women, and 11 provide pregnant women with priority access to state-funded drug treatment programs.

Four states prohibit publicly funded drug treatment programs from discriminating against pregnant women.

Nurses should understand the many barriers that exist for women, especially pregnant women and new mothers, who try to undergo treatment for drug addiction. Access to treatment is one such barrier; there are too few treatment programs, forcing new mothers to travel a great distance to undergo treatment, and treatment must often be paid for out of pocket.[4]

A significant barrier to seeking treatment may be the fear of losing their babies,[5] a problem that will be exacerbated if more states follow Tennessee's lead and criminalize drug use in pregnancy. It is important for nurses to be aware of the laws in their states that affect mothers who took drugs while pregnant and to keep abreast of changes in the law. It makes little sense to spend weeks helping neonates overcome the effects of prenatal drug exposure, if their mothers fail to receive the treatment they need for their own drug use.



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