The recent rise in opioid use has received attention across the country, as lawmakers, advocates, and public health officials attempt to figure out the best way to address this crisis at the local, state and federal levels. As this issue is scrutinized, the majority of the attention has gone to adults, who are the primary users of opioids. When children are included in the conversation, it is often in the context of adolescents, and strategies to identify and assist youth who may be engaging in harmful substance use. However, this issue also affects another segment of the population that has received less attention: infants exposed to substances during pregnancy.
Impact of Opioids on Newborns
The effects of pre-natal substance exposure to alcohol and nicotine have been well documented. But the opioid crisis has also given rise to increased prevalence of the specific symptoms associated with pre-natal opioid exposure, known as neonatal abstinence syndrome (NAS), which can have severe detrimental effects on the child. Despite the potential negative effects of substance exposure (including, but not limited to NAS), research has shown that the post-natal environment is critical to a child’s development, and that many of the adverse effects substance-exposed newborns experience can be overcome through robust, coordinated care for infants and their whole family.
Fixing a Broken System of Care for Substance-Exposed Newborns
Unfortunately, the existing systems of care for substance-exposed newborns are often disconnected and difficult to navigate. Prompted by this knowledge, the children’s health team at Community Catalyst convened a working group in Massachusetts to assess the current situation within the state, and learn how it can be improved by sharing information, promoting coordination and identifying potential areas for action and advocacy. We recently produced a memo summarizing the work and findings of this working group. It may provide guidance not only for people in Massachusetts, but also a template for those in other states who are working to address this issue. While each state is unique, some of the findings and strategies from the working group are certainly transferrable to other states. Examples of these findings include:
- Approaching the issue through a two-generation lens is critical. Treating the mother and child and as a unit, rather than as separate cases, provides the best opportunity to ensure positive outcomes for both mother and child throughout their lives.
- Coordination and communication is a critical but challenging aspect of ensuring care for substance-exposed newborns and their mothers. This challenge manifests itself at two related but distinct levels: the provider level, and the state agency level. At the provider level, care for a mother and her substance-exposed newborn often involves a number of different organizations and individuals. This makes it difficult to communicate, and by extension, difficult to provide adequate levels of care. At the state level, different agencies may have a hand in monitoring and overseeing these cases, but lack of communication between these agencies can jeopardize the long-term quality of care these infants and their mothers receive.
- To facilitate better coordination and communication at all levels, states can implement systems and protocols to collect data, track cases, and create mechanisms for appropriate referrals and follow-ups. Using these steps to coordinate care can ensure that families receive care that is more efficient, robust and comprehensive. In order to gain a clearer sense of what the existing landscape and systems look like in their state, advocates can gather together individuals from different sectors to share information. This might include, among others:
- Child welfare agencies
- Representatives from the recovery community
- Providers, including clinicians and other representatives from hospitals
- Public health officials, including representatives from early intervention and behavioral health
State and Federal Solutions
In certain states, new initiatives and proposals to address the opioid crisis incorporate some of these strategies, and may provide examples of how they can be put into practice. After the death of an 8-month old child with NAS in Delaware brought increased attention to the issue, the state re-examined how its various agencies can improve protocols to avoid similar tragedies. A new proposed bill would more explicitly define plans of safe care for substance-exposed newborns, including requiring reports by social workers, nurses and hospitals, so information can be shared and analyzed to ensure infants are not in danger. In New Hampshire, Dartmouth-Hitchcock Medical Center re-thought their model for caring for substance-exposed newborns, and began new practices that emphasized the importance of the mother-infant unit. This new focus has yielded tremendous results, including shorter hospital stays, reduced reliance on morphine for treatment and lower costs.
At the federal level, the issue of substance-exposed newborns prompted bipartisan cooperation, as Congress passed the Protecting Our Infants Act of 2015, sponsored by Sen. Mitch McConnell (R-KY) and Rep. Katherine Clark (D-MA). This new law requires HHS to assess the current standards for treating NAS and develop further recommendations for treatment, which may include working with state health departments to provide assistance and determine best practices. Earlier this year, the White House-convened Commission to Eliminate Child Abuse and Neglect Fatalities released an extensive report on child welfare entitled ‘Within our reach: A national strategy to eliminate child abuse and neglect fatalities’. While this report addresses a myriad of issues around children’s welfare, the commission identifies substance-exposed newborns as an important issue, and calls for an increased focus on improving treatment for these infants.
The recent opioid epidemic will continue to receive attention at both the state and federal levels, as evidenced by recently adopted legislation in Massachusetts, and pending legislation in Connecticut, Vermont and elsewhere. As advocates and officials look at ways to address this problem among adults, it is important to remember to include infants in the conversation. Treating substance-exposed newborns and their mothers can be complex, but working to develop comprehensive plans of care that address the issue through a two-generation lens is critical as we continue this discussion.