‘Hugs Not Drugs’ for Opioid-Dependent Newborns

Study finds reduced length of stay, less need for medication

by Elizabeth Hlavinka

The "Eat, Sleep, Console" treatment for infants born with opioid dependence decreased length of stay and use of narcotics, according to a retrospective study presented here.

The number of infants treated with postnatal opiates decreased from 83% to 20% within 18 months after implementing the tool in the Colorado Hospital Substance Exposed Newborn Quality Improvement Collaborative, reported Susan Townsend, MD, of the University of Colorado School of Medicine in Aurora, and colleagues.

This intervention -- a formal program to educate parents on proper feeding and soothing methods -- also decreased median length of stay from 17 days at pre-implementation baseline to 4 days afterward, according to her poster at the annual Pediatric Academic Societies meeting.

"What we don't know is what the long-term impacts of this approach are -- if it's going to be better, worse, or the same -- and that's a problem and is important to follow up on," Townsend said here. "But what we do know is babies can be managed through withdrawal with this non-pharmacologic approach we are calling 'hugs not drugs,' and can successfully go home sooner."

There are currently "no uniformly accepted pharmacological interventions or standardized regimens for the management of neonatal abstinence syndrome," according to the American Academy of Pediatrics. Treatment protocol is typically based on the Finnegan Neonatal Abstinence Scoring Tool (FNAST), in which 21 behaviors associated with withdrawal such as sneezing, vomiting, and diarrhea are evaluated to determine which treatment the infant should receive.

The AAP does recommend pharmacologic treatment (most commonly morphine or methadone) when supportive therapy fails, withdrawal scores remain high, and complications such as seizures or severe dehydration occur.

Elisha Wachman, MD, of Boston Medical Center, who co-authored the intervention's guidelines, but was not involved with this study, also cautioned that the "Eat, Sleep, Console" tool needs more study.

Not only are long-term outcomes unknown, but it also remains unclear whether infants are going home sooner but with more readmissions later, she told MedPage Today. Effects on their later development are also uncertain. On the other hand, narcotics' subsequent effects on the developing brain and immune system of these infants remain unknown as well, she added.

Wachman emphasized that there are still many infants that would benefit from medication, particularly those who are inconsolable or who are prevented from eating or sleeping appropriately due to withdrawal symptoms.

"But I don't think that number is 80% or 90%, which is where many centers used to be or still are, using a protocol that says a very large percentage of babies meet criteria for medication," Wachman said. Although the proportion of infants actually requiring medication is unclear, she added, it could be as low as 30%.

"What was happening a lot before was babies were getting too much medication and if you kept them on it for too long ... they could develop a dependence on that medication."

Townsend noted that calming techniques used for infants such as teaching them to self-soothe or increasing skin-to-skin contact have been shown to improve state control and regulation, and generally support healthy development. Narcotics could interfere with the positive effects of these physiologic methods, she said.

Her study involved 112 opioid-exposed newborns who entered the center's neonatal intensive care unit (NICU) from October 2017 to March 2019, born at least 34 weeks' gestation without anomalies.

In addition to a reduction in the number of infants exposed to opioids, researchers also observed a reduction in median duration of postnatal treatment with opiates, from 12 to 2 days across the study period, Townsend reported.

Both Wachman and Townsend emphasized that in order for this tool to be used effectively, it should be implemented with a comprehensive care system that ensures infants are not overstimulated, are getting enough skin-to-skin contact, and are "rooming in" with parents.

"If you don't have everything else in place in terms of rooming in and developing a supportive environment, you may not see the same results," Wachman said. "It's a whole-package intervention and I think that's something people should really recognize -- the tool is one piece, but just implementing that and ignoring the rest isn't the right answer."

Primary Source

Pediatric Academic Societies

Source Reference: Townsend S, et al "Rapid decrease in length of stay and postnatal use of opiate medication using 'Eat, Sleep, and Console" PAS 2019; Publication number 3545.4.

Comments

endocannabinoid deficiency has been documented in opioid addiction including epigenetic changes. Non-psychoactive cannabinoids (NPC) have been effective at controlling addiction, withdrawal and behaviors in animal models and considerable number of case reports. NPC have no significant adverse effects but could restore balance to the ECS (endocannabinoid system). Endocannabinoid signalling in reward and addiction. CB1 Agonism Alters Addiction-Related Behaviors in Mice Lacking Mu or Delta Opioid Receptors. Planta Med. 2017 Aug 9. doi: 10.1055/s-0043-117838. [Epub ahead of print] Effects of Cannabidiol on Morphine Conditioned Place Preference in Mice. Neuroscience. 2017 Jul 17. pii: S0306-4522(17)30488-8. doi: 10.1016/j.neuroscience.2017.07.018. [Epub ahead of print]
Effects of cannabinoid drugs on aversive or rewarding drug-associated memory extinction and reconsolidation. Neuropharmacology. 2017 Sep 15;124:73-83. doi: 10.1016/j.neuropharm.2017.05.031. Epub 2017 May 28.
The endocannabinoid system as a target for addiction treatment: Trials and tribulations. Br J Pharmacol. 2017 Oct;174(19):3242-3256. doi: 10.1111/bph.13724. Epub 2017 Mar 9.
Cannabidiol regulation of emotion and emotional memory processing: relevance for treating anxiety-related and substance abuse disorders.

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