The Opioid Crisis: Navigating Impact on Pregnancy & Newborns
by Rose L. Horton, MSM, RNC-OB, NEA-BC, FAAN
Originally published by Synova Associates
How can we mitigate the public health crisis of opioids and its impact on pregnancy to pediatrics understanding that lives, healthcare and communities bare the brunt of the crisis? It’s estimated that ~7% of pregnant women report opioid use. Roughly 256K newborns are born opioid exposed each year resulting in a $1.5B annual cost. This is a national crisis with varying degrees of impact per state. For example, Kentucky has a Neonatal Abstinence Syndrome (NAS) rate of 19/1000 hospitalizations while Appalachia is 77/1000, and Wyoming is 3/1000.
What we know about substance use disorder (SUD) is that it is a disease. It is important to note that genetics accounts for 50%, there is usually a history of trauma or stressors, and it tends to occur with psychiatric illness. In 2022 more than 2.5 million people had both SUD/AMI – any mental illness. This disease is non-discriminatory in that it affects all socioeconomic, gender, race and ethnicities. It is complex, chronic and relapsing, with greater than 80% relapse postpartum within 12 months. It causes significant craving for more drug, leads to compulsivity and there is continued use despite harmful consequences. The disease also leads to impaired executive function which means that perception, learning, impulse control and judgment are altered.
Many contributing factors have led to the opioid crisis. In 1804, morphine was first extracted from the opium poppy plant. It was in 1889 when heroin was invented from morphine. History only gets more interesting and fascinating. The year was 1989 when NIH supported pain as the 5th vital sign. There was a demand for specialists and primary care providers to treat pain. Relieving Pain in Medicine: A Blueprint for Transforming Prevention, Care, Education & Research report was published by The Institute of Medicine in 1990. Shortly after there was a promotion of ‘common wisdom’ that opiates are not addictive. In 2012, overdose accounted for 48 deaths/day. In 2015 it was noted that there were 136 million prescriptions of oxycontin.
Based on a national survey on drug use and health 2016- 2022, the use of THC has increased 39% from 2016; 15% since 2021. Prescription opioids decreased 4.1% from 2015. It is estimated that a third of those who use prescription opioids misuse them and the remaining 2/3 use medications as prescribed. There has been a 59% reduction of opioid prescriptions since 2020. A 30% increase in hallucinogens and 26% increase in methamphetamines. There are a fair number of emerging substances that vary based on state and location.
How does all of this influence the birthing community? The Centers for Disease Control, CDC reported in 2023 that 84% of maternal mortality is preventable and 23% of deaths are attributed to mental health conditions to include death to suicide and/or overdose. Additional effects on pregnancy, fetus and the newborn are:
| Maternal | Fetus | Newborn |
|---|---|---|
| Overdose/death | Spontaneous abortion | Small for gestational age |
| Poor nutrition | PTL and birth | Placental insufficiency |
| Increased rates of tobacco, THC use | Fetal hypoxia | Altered brain organization |
| High risk behavior | Exposure to infection | |
| Poor prenatal care | Exposure to violence |
Though the opioid crisis is complex, daunting, multi factorial and overwhelming, there’s great news to share. One is that pregnancy is an amazing motivator for birthing people to seek treatment. Also, we, as nurses and nurse leaders can significantly impact outcomes. In the article Unpacking Perinatal Experiences with Opioid Disorder: Relapse Risk implications, the authors list 8 relative risk factors.
Relative Risk Factors:
Maternal “childhood” bond
Preparedness for pregnancy
Pregnancy and postpartum attachment
Birth experience support
Breastfeeding
DCS involvement
Mental health
Recovery and follow up plan
Of the eight factors there are several that we can directly influence, and I want to focus on two of them: 4 and 5.
In the article the respondents spoke to the value of having family or partners present for birth as very important to them. Additionally, supportive and nurturing staff to include the nurse, is equally important. Showing up for patients in a manner that demonstrates professionalism and genuine concern is a ‘protective factor’ in mitigating the opioid crisis. The American Nurses Association (ANA) Code of Ethics state that “the nurse practices with compassion and respect for the inherit dignity, worth and unique attributes of every person.” Our duty as professional nurses is to lead with compassion and respect. I have heard Cy Wakeman say ‘you can help or you can judge.’ When caring for a laboring patient who is struggling with opioid use disorder and on methadone, our duty is to lead with compassion and respect and not to ascribe to judgment. When caring for neonate who has a high Finnegan score and is symptomatic, our duty is not just to initiate ‘eat, sleep console’ care but also to be intentional in being non-judgmental in our interactions with parents.
Nurses also strongly impact the patient’s decision and success in breastfeeding. Respondents in the article mentioned that breastfeeding was a significant bonding experience. There are many documented benefits of breastfeeding, human milk, and being skin to skin for both mothers and newborns. For some dyads, breastfeeding comes easily however, that is not the case for everyone. Having supportive nurses and lactation consultants who are willing to take the time and extend grace to women is closely correlated to breastfeeding success. Taking the time to teach the family how to express milk, how to pump along with how to help the baby latch and position for breastfeeding is a unique opportunity for nurses.
I had the incredible opportunity to work with a neonatologist, Dr. K.D. Forbes, in creating a compelling podium presentation on the topic of the Opioid Crisis and most of this content is derived from that presentation. Sponsored by Mead Johnson Nutrition a few of us created a virtual education that is free and offered quarterly. The next virtual conference is scheduled for August 29, 2024: Shaping a Stigma-Free Narrative – Empowering LGBT+/Trans Individuals, Promoting Trauma-aware Care and Understanding the impact of Language. The 4-hour education is rich with actionable content curated for the perinatal and neonatal nurse.
Be on the lookout for the November Reckitt Mead Johnson Nutrition blog where I will focus solely on mitigating stigmatizing language in our interactions with the birthing community.
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