The opioid epidemic has touched every stage of life, including women who are pregnant and their babies.

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Abstract According to Bowlby, infants have a universal need to seek close proximity with their caregiver when under distress or threatened. This study seeks to look at attachment in a population that is undergoing extreme distress as they suffer from opioid withdrawal within the first few weeks of life. It aims to explore the role touch (kangaroo care) can have in creating the secure base that attachment theorists describe as the basis for all future attachments, and in reducing the length of Neonatal Abstinence Syndrome. It is hypothesized that infants born with drug dependencies who receive increased touch and holding throughout their withdrawal will have a shorter duration of Neonatal Abstinence Syndrome and will be more securely attached at 18 months than those who do not receive increased touch. It is also hypothesized that infants whose caregivers reported high scores of bonding with their infants in the first year of life will be more securely attached than those with lower scores of bonding. Infants who were sent home with their birth parents after discharge are hypothesized to be more securely attached at 18 months with their caregiver than infants who were sent home to a foster family. The results of this study will contribute to attachment literature in a population where research is lacking, and will add to the knowledge on Neonatal Abstinence Syndrome treatment.

Background: The opioid epidemic is particularly worrisome in the pregnant population, wherein concerns are raised about the health of a mother and her child, resulting in an alarming incidence and prevalence of Neonatal Abstinence Syndrome (NAS). The 2016 National Survey on Drug Use and Health (NSDUH) show the rate of illicit psychoactive substance use among the females aged 12 or older was 15.5% in the past year. Among pregnant women aged 15 to 44, 6.3% were illicit psychoactive substance users. In Tennessee, the number of hospital discharged NAS cases from 2002 to 2013 increased from 1.50 to 16.6 cases per 1,000 live births. This number is triple the national incidence of NAS cases over the same time period. Between 2013 and 2016, at least 52.5% of children diagnosed with NAS in Tennessee have had exposure to one prescription drug, while 27.2% were exposed to a combination of prescribed medications and illicit substances. We examined the behavioral correlates that determine the wish to quit opioids or not to quit opioids among opioid-dependent pregnant and non-pregnant women in rural Appalachia. Methods: Ten women of childbearing age, whether pregnant or not, who were receiving prescribed opioids, were recruited to join the study. All the participating women were also receiving physician-managed Medication Assisted Treatment (MAT) therapy for the treatment of severe opioid use disorder, or are currently being prescribed an opioid medication. Study variables included age, Hamilton Depression Rating Scale (HAM-D), Visual Analogue Scale – Pain (VAS-P), the Modified Opiate Craving Scale (MOCS), the Visual Analog Commitment to Quit Opiates, the McGill Pain Index (MPI), prescriptions, tobacco and nicotine use, illicit substance use, the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), and the Adverse Childhood Experience (ACE) questionnaire. The HAM-D, MOCS, MPI, and SOCRATES scores were log-transformed to approximate a normal distribution. Descriptive statistics and the Spearman’s rank correlation (with a 95% Confidence Interval) were conducted to examine significant behavioral correlates for quitting opioids. Results: Descriptive statistics show that women with higher HAM-D and MOCS scores are not likely to express willingness to quit opioids. There is a statistically significant strong positive correlation of 0.679 (pppp Conclusion: Women who recognize the need to quit opioids or are “taking steps” to quit are more likely to quit opioids. Women with high depression and pain scores are not likely to quit opioids. Non-opioid medications may reduce the number of opioid-dependent pregnant and non-pregnant women of childbearing age, and, in turn, lower the currently high incidence and prevalence rates of NAS.

Chronic opioid exposure in utero places the infant at risk of Neonatal Abstinence Syndrome (NAS), a clinical diagnosis of neurological, autonomic, and/or gastrointestinal withdrawal symptoms from opioid abstinence at birth. The prevalence of NAS is rising concurrently with the recent epidemic of opioid misuse among the general population in the United States, including pregnant women. Opioid misusing women typically receive methadone or buprenorphine as a treatment throughout pregnancy. However, the opioid misuse during pregnancy is associated with higher obstetric complications and a higher incidence of NAS in infants, at times requiring pharmacological intervention. The exact consequences to the human development from opioid exposure in utero remain unclear. Animal studies suggest that the fetal impacts of opioid exposure may differ from the consequences for an adult who uses opioids. Furthermore, there may be neurodevelopmental alterations in myelin physiology, dendritic length in the brain, and neurotransmitter systems when a child is exposed to opioids in utero. Clinical studies highlight associations between perinatal opioid exposure and gene mutation variants, cranial abnormalities on imaging, and a high prevalence of ocular and visual comorbidities. Ocular and visual comorbidities are of particular interest, because they may be treatable when detected early. The current literature about NAS infants and ocular and visual comorbidities is limited by the retrospective and small case-control study designs employed by the majority of the research groups. The proposed study design is a prospective study comparing groups of opioid exposed and non-opioid exposed infants born at Boston Medical Center in Boston, Massachusetts. The ocular and visual comorbidities detected in each group will be quantified, while analyzing the relationship and the relative risk attributable to the infant’s and mother’s demographics. The social context of opioid misuse may complicate the interpretation of the data; however, the design anticipates sufficient recruitment and generalizability as it is conducted at a safety net hospital. Ultimately, the goal of this proposal is to reduce the risk to the fetus with perinatal opioid exposure and build the knowledge base about ocular comorbidities in NAS infants so that optimal and comprehensive care can be provided in the future.

Background: Prenatal exposure to opioids, cocaine, and methamphetamine is associated with alterations in fetal brain that lead to structural changes in the brain postnatally, contributing to developmental and behavioral effects seen throughout childhood. Opioid exposure is associated with withdrawal in newborns, effects on somatic growth of infants, difficulty with executive functions and a tendency towards externalizing behaviors in older children. Cocaine and methamphetamine exposure are associated with effects on somatic growth, irritability and feeding issues in infants, problems with executive functions, and externalizing behaviors. Many substance-exposed children are placed in foster care and the pre-licensure training for foster parents does not specifically address how to care for substance-exposed children. Purpose: To create and evaluate a video that outlines common effects of prenatal exposure to opioids, cocaine, and methamphetamine, as well as evidenced-based caregiver interventions. Methods: The script for the video “Caring for Children with Prenatal Substance Exposure: Opioids, Cocaine, and Methamphetamine” was written by the author and evaluated by two clinical experts. The video was filmed and was presented to 6 licensed foster parents and 1 unlicensed adoptive parent who evaluated the video’s presentation at Devereux Foster Care Agency in Tucson, AZ using the Patient Educational Materials Assessment Tool for Audio/Visual (PEMAT-AV). Responses were entered into the PEMAT Autoscoring tool and component scores for understadability and actionability were calculated. Results: Both clinical experts evaluated the video’s content as being factual, and consistent with evidence-based research. Mean PEMAT-AV understandability and actionability scores were both 100%. Discussion: The video’s content and presentation are both strong as evidenced by high evaluation scores from clinical experts and foster parents, making it a useful educational tool for educating foster parents on caring for substance-exposed children. Further research is needed to determine if the viewing video increases foster parent knowledge and produces long-term change in parenting practices. Additionally, the video was designed to also be used to educate biological parents of substance-exposed children, but future studies are needed to determine if the video is an effective educational tool for this population.

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In Part 2 of this 2 part sequence, use of abstinence assessment tools to rate NAS scores will be discussed to guide understanding of withdrawal symptoms commonly observed. Abstinence tools will be compared and contrasted against infant assessments commonly used by therapist to guide neurodevelopmental implications of symptoms. Guided by NAS assessments non-pharmological management will be addressed including environmental adaptations, state regulation, rest and sleep (use of swaddling, nonnutritive sucking, rocking, positioning), feeding (formula and breastfeeding). Applied examples of the therapist role in NICU along with treatment interventions for infants and their families will be discussed. Once the caregivers within the NICU are better to understand the scope of the problem, this knowledge will translate into improved developmentally supportive and age appropriate care. A through understanding of infants with NAS and their families will lead to more responsive care for their infants during and after their hospital stay.