Opioids in Pregnancy: What Raises the Risk for Neonatal Abstinence?

William T. Basco, Jr., MD, MS


August 24, 2015

Study Findings

There were more than 112,000 pregnant women in the cohort, 28% of whom had received at least one opioid prescription during pregnancy. Use of tobacco and receiving an SSRI were both more likely to occur in women who had received opioid prescriptions. The overwhelming majority of the opioid prescriptions (96.2%) were for short-acting medications. Only 2.7% received maintenance opioids, and 0.6% received a long-acting opioid. A total of 1086 infants were diagnosed with NAS, 65% of whom were born to mothers who had received at least one opioid prescription. Among infants exposed to maintenance opioids (eg, buprenorphine hydrochloride), 29.3% developed NAS. Of infants exposed to long-acting opioids, 14.7% developed NAS, compared with only 1.4% of those exposed to short-acting opioids.

Higher percentages of respiratory diagnoses, difficulties with eating, and seizures were found among infants with NAS compared with those who did not exhibit NAS. After adjusting for maternal factors, infant factors, and calendar year, the investigators found that cumulative exposure to short-acting opioids, any exposure to the longer-acting opioids, cigarette exposure, and the use of SSRIs within 30 days prior to delivery were all positively and independently associated with the likelihood of the infant developing NAS. The different independent associations were additive, such that the highest risk of developing NAS occurred among infants who were exposed to opioids for 25 weeks or longer, whose mothers smoked 20 cigarettes a day or more, and whose mothers were prescribed an SSRI. Of those infants, 36.6% developed NAS compared with 0.01% among infants exposed to short-acting opioids for up to 5 weeks but without tobacco or SSRIs.

The rate of NAS in the overall cohort almost doubled in a relatively short, 3-year period. The investigators concluded that the use of opioids in pregnancy is common and has strong associations with NAS. Patterns of opioid exposure as well as opioid type, with concomitant tobacco or SSRI exposure, increase the chance that an infant will develop NAS.


The American Academy of Pediatrics[1] recommends observation for up to 4 days in an infant who exhibits NAS, but most nurseries use combinations of symptom scores and other measures of infant well-being to decide on the timing of discharge. The data about the additive risk of tobacco smoke or SSRIs are very interesting and can help clinicians identify populations to watch more carefully.



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