Due to the ongoing opioid crisis plaguing the nation, the American Congress of Obstetricians and Gynecologists said Wednesday that an approach to treating babies born with addiction that was once thought to be harmful should now be considered.
In 2012, an estimated 21,732 babies were born with neonatal abstinence syndrome, or NAS. That's a baby born addicted to opioids every 25 minutes, according to the National Institute on Drug Abuse. And as soon as the infant is out of the womb, it begins detoxing from the drugs that were passed through the mother's placenta. According to the March of Dimes, most often those drugs are opioids. Between 2000 and 2009 the number of delivering mothers using or dependent on opioids increased nearly fivefold. It's a harsh reality that is part of the opioid epidemic that has wreaked havoc across the nation.
Conventional wisdom has been that stopping opioids or detoxing mothers during pregnancy was too risky for the fetus as well as the mother, but ACOG has taken another look at this practice in light of the overdose crisis. Those risks include stillbirth and fetal stress.
Medically assisted treatment, or MAT as it's referred to, slowly weans someone who is addicted to opioids off the drugs they are using with the aid of other medications such as buprenorphine or methadone, along with behavioral therapy. This, too, is not without risk to the mother, or the unborn baby, who can eventually be born with NAS. However, MAT has been associated with improved prenatal care, lower rates of complications during pregnancy and higher rates of compliance to addiction treatment. Unlike MAT, medically supervised withdrawal is the tapering off an opioid without the aid of a medication, but still coupled with the other support services.
Dr. Maria Mascola, who leads ACOG's committee on obstetric practice, said that while MAT remains the gold standard to help a mother taper down her use of opioids, there was some recognition that withdrawing with the help of a physician and other support services could be effective. "There is a growing body [of studies] that says it can be safe, but the data is still limited," said Mascola.
"For this to be successful it often requires prolonged inpatient care and intensive outpatient behavioral health follow up," said Dr. Mark Turrentine, OB/GYN at Texas Children's Pavilion for Women. Turrentine was not involved with the committee's decision.
Support is key
Dr. Alfred Abuhamad, president of the Society for Maternal Fetal Medicine, said, "If you have the resources and you have the support, and the expertise on the health care team, the psychosocial support ... this is an option that doesn't seem to be associated with complications as we thought in the past. It is an option viable for a pregnant woman if she chooses to do so, but it is really important to support those interventions." Abuhamad is also not part of the committee.
Mascola agreed, pointing to studies showing high relapse rates ranging from 59% to more than 90% in some cases -- the distinction in these situations being a lack of long term followup. "If they relapse, it can be dangerous ... they could go back to illicit drug use or overdose," said Mascola.
Dr. Craig Towers, who specializes in high-risk pregnancies at The University of Tennessee Medical Center, says medically assisted detoxing can be very successful. Towers has helped detox more than 500 mothers. He was not involved in the committee's decision-making. "I am glad to hear ACOG is recognizing that medically supervised withdrawal under the care of an experienced physician can be offered to pregnant women with opioid use disorder as an additional option beyond MAT (medically assisted treatment). This approach is very successful when connected with behavioral health and results in [babies] born who do not suffer from NAS," said Towers.
Long-term outcomes of babies born with NAS are still unclear, even though it has been linked to poorer outcomes in school and increased risk of ADHD.
Still more research needed
Mascola said the change in thinking was driven both by patient conversations and new data looking at medically supervised withdrawal that not only saw success for the mothers, but also positive outcomes for the infants. "There wasn't really any data to support that and we wanted to adhere to what we knew," said Mascola, referring to stillbirth and fetal stress.
However, she cautioned that the data was limited and there are still a lot of questions about who this protocol may work for. "We're still learning that, we would love to determine who it is successful for. Those who maybe don't have easy access [to MAT]? Those who are highly motivated?" said Mascola.
"Abstinence-based approaches don't do well for most patients ... and being pregnant doesn't necessarily change that equation" said Dr. Andrew Kolodny, former chief medical officer of the Phoenix House Foundation. Kolodny was not involved in the committee's decision but pointed out that pregnancy can be a particularly stressful time for women, who then are also dealing with addiction. He said that while this may be a good option for women with mild opioid addiction and dependency issues, he was doubtful about this approach for patients who were severely dependent on prescription painkillers or heroin.
But in areas where access to buprenorphine or methadone are limited because the availability of the drugs is limited to specific providers or clinics, Mascola says medically supervised withdrawal could be an option. However, as Abuhamad questions, "If [mothers] don't have access to methadone or buprenorphine -- will they have access to [the resources needed for] medically supervised withdrawal?"