Senate HELP Committee Issues Testimony From Vanderbilt University School of Medicine
"Chairman Alexander, Ranking Member Murray and honorable members of the Committee, thank you for the opportunity to speak here today about the impact of the opioid epidemic on our nation's families. My name is Dr.
"Recently, I was caring for a sick infant at Vanderbilt who had been transferred to our neonatal intensive care unit from the newborn nursery. The infant had trouble feeding, was jittery and had rapid weight loss - more than ten percent of his body weight in a few days. Something was wrong.
"The infant was exhibiting classic signs of neonatal abstinence syndrome, a post-natal drug withdrawal syndrome that most commonly occurs after in utero exposure to opioids, but like many conditions, neonatal abstinence syndrome can be difficult to diagnose in the newborn. Over the next few days, the infant was increasingly irritable, continued to have difficulty feeding, increased muscle tone and muscle jerking. We suspected opioid withdrawal, but his mother denied using any drugs. Despite this, we started treating the infant as we would any infant with the syndrome.
"After a week in the hospital, the umbilical cord drug screen came back positive for an opioid. As I walked into the infant's room to talk to his mother I could sense her guilt and anxiety. She cried as I talked to her about the drug test, and wondered aloud if she would lose custody of her infant. She had been afraid of my response and the response from child welfare. Like too many women I see, she became dependent on an opioid after an accident, was not able to get treatment for her opioid use disorder while pregnant and was too scared and ashamed to ask for help. This combination was dangerous to her and her infant.
"Had I known this mother was using an opioid, I could have started treating the baby earlier by controlling the environment, making adjustments to the baby's care to make the withdrawal less severe while teaching his mother how to recognize and mange his symptoms. Perhaps more optimally, his mother could have already had access to comprehensive treatment during her pregnancy.
"As a practicing neonatologist, I have seen first-hand the destructive impact of opioids on families. Neonatologists like me are trained to care for very premature infants and infants with severe birth defects. However, a few years ago we began to see an influx of a different type of infant - those having withdrawal from opioids, known as neonatal abstinence syndrome. These infants can be inconsolable, have muscle tremors, have trouble feeding, difficulty sleeping and breathing problems.
"Infants experiencing severe neonatal abstinence syndrome require treatment with an opioid like morphine or methadone, and stay in the hospital an average of more than three weeks.1 Once rare, this diagnosis has become increasingly common. Our team's research has found that from 2000 to 2014, the number of infants diagnosed with neonatal abstinence syndrome grew nearly 7- fold.1-3 Put another way, nearly one infant is born every 15 minutes with signs of drug withdrawal in the US.3i
"This rise in the incidence of neonatal abstinence syndrome happened in parallel with increases in opioid use nationally. In 2015, Americans were prescribed three times as many opioids as they were in 1999.4 That year, more than 37 percent of American adults were prescribed at least one opioid pain reliever.5 Research, including our own, has found similarly high rates of opioid prescribing in women of reproductive age6 and pregnant women.7 More recently, we have experienced a surge in use and complications due to heroin and fentanyl use. In 2016, more than 42,000 Americans died from an opioid overdose death8 and some of them were pregnant or had recently been pregnant.
Implementation of Existing Legislation
"I applaud the Committee and the
Protecting Our Infants Act
"The Protecting Our Infants Act was passed just after a Government Accountability Office (GAO) report highlighted large gaps in research and service delivery for mothers and infants impacted by opioid use.9 The Act required that the
Comprehensive Addiction and Recovery Act & the Child Abuse Prevention and Treatment Act
"The already-taxed child welfare system is being stretched even more thinly by the opioid epidemic. In 2015, the number of children entering foster care increased to nearly 270,000, up from 251,352 in 2012. In 2015, infants represented nearly one-fifth of all removals of children from their families to foster care, totaling 47,219. Parental substance use was a factor in the foster care placement in nearly one-third of all cases.10
"
"Unfortunately, those requirements came without clear guidance or, importantly, sufficient resources for implementation. States need additional guidance, funds, and resources from the federal government to ensure infant safety and to keep families intact when appropriate. States and communities need assistance to develop their key definitions and need funding for services to address these families' needs. I have experienced first-hand how these changes in statute are being interpreted with great variability among doctors, hospitals and child protective services. I would encourage the Committee to continue to exercise robust oversight of the federal agencies working with states on implementing and monitoring CAPTA, and to provide funding additional legislative clarity where needed.
"In addition to the severe gap in funding the CAPTA-required plans of safe care, funds to ensure family-centered treatment are currently lacking.
"Treatment programs for pregnant and parenting women funded under the block grant need expansion because the program has not changed in nearly 20 years.11 It is time for
Recommendations
"Addressing the complexity of perinatal opioid use and neonatal abstinence syndrome requires a thoughtful public health approach targeting the pre-pregnancy, pregnancy and post-pregnancy periods for women and infants. Our goal should be to promote healthy mothers and infants by supporting prevention and recovery:
"My recommendations fall into three broad categories: improving care for mothers, improving infant outcomes, and research.
Improving Care for Mothers
"Primary prevention of opioid use disorder begins with preventing unnecessary opioid use well before pregnancy. Non-medical use of opioids among adolescents commonly begins with opioids not prescribed to them, but rather to a family member or friend.
"Too many health care providers are still unaware of the implication of their prescribing patterns for their patients. It is clear that additional provider education in this area is greatly needed.
"Improving access to contraception, including long-acting reversible contraception, is vitally important because research suggests that women with opioid use disorder are nearly twice as likely to have an unplanned pregnancy.13
"
"
Improving Infant Outcomes
"Throughout the US, opioid-exposed infants experience variable treatment28 resulting in variable outcomes.29 State and national perinatal quality improvement groups and hospital teams like ours at Vanderbilt are working to decrease this variability, but
"Medicaid programs are well-positioned to achieve the "triple aim" for families impacted by opioid use, by improving population health, improving the experience for pregnant women and infants and reducing cost.30
"Our nation has a long way to go to improve care for infants with neonatal abstinence syndrome, from better identification and treatment (including non-pharmacologic treatment) to improvements in the structure of care and minimizing separation of the maternal/infant dyad. Systems need to be agile, responding to new complications of the opioid-epidemic like hepatitis C. In a study conducted in partnership with the
"We also must do a better job of supporting families in the transition to home through initiatives like home visiting. The Maternal, Infant, and Early Childhood Home Visiting program provides funding to states to implement and expand effective home visiting programs that improve the early health, school readiness and economic stability of children and families. High-quality home visiting services to infants and young children can improve family relationships, advance school readiness, reduce child maltreatment, improve maternal-infant health outcomes, and increase family economic selfsufficiency. 33 However, funding for the program expired
"Next, the Individuals with Disabilities Education Act (IDEA) Part C supports early intervention services, like speech therapy, physical therapy and occupational therapy to infants with developmental delays. In 2004, reauthorization of this program extended to substance-exposed infants and infants having drug withdrawal after birth; however, adoption has been uneven. While as a provider I refer substance-exposed infants to early intervention services, it is not clear how many others are.
Research
"In 2015, the GAO highlighted research gaps and reasons for the difficulty of conducting research on prenatal substance use and neonatal abstinence syndrome.9 As the GAO report noted, the federal government spent only
"
Summary
"The opioid epidemic is taking a terrible toll on pregnant women and infants.
"Every day, people are dying, pregnant women are not getting the treatment they need and infants are spending their first days or weeks of life in drug withdrawal. In just the time we are meeting here, 8 infants will be born with neonatal abstinence syndrome and 10 people will die from an overdose.
"These are our brothers and sisters and our children - they need us, now perhaps more than ever.
"
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Footnotes:
i Results embargoed, but permission to cite given by editor. Paper will appear online in the journal Pediatrics in March.
ii http://www.wbir.com/article/news/local/mother-of-drug-dependent-baby-tells-her-story/51-63840991
iii Results embargoed, but permission to cite given by editor. Paper will appear online in the journal Pediatrics in March.
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