Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal

Young, Leslie; Ounpraseuth, Songthip; Merhar, Stephanie L.; Hu, Zhuopei; Simon, Alan E.; Bremer, Andrew A.; Lee, Jeannette; Das, Abhik; Crawford, Margaret; Greenberg, Rachel G.; Smith, P. Brian; Poindexter, Brenda B.; Higgins, Rosemary D.; Walsh, Michele C.; Rice, Ward R.; Paul, David A.; Maxwell, Jessie R.; Telang, Sucheta; Fung, Camille; Wright, Tanner; Reynolds, Anne Marie; Hahn, Devon W; Ross, Julie A.; McAllister, Jennifer; Crowley, Moira; Shaikh, Sophie K.; Puopolo, Karen M.; Christ, Lori; Brown, J. Ahmad; Riccio, Julie; Ramsey, Kara Wong; Akshatha,; Braswell, Erica; Tucker, L; McAlmon, Karen R; Dummula, Krishna; Weiner, Julie; White, Jessica; Howell, Meghan P.; Newman, Sarah; Snowden, Jessica; Devlin, Lori A.

doi:10.1056/nejmoa2214470

Cited by 57 publications

(31 citation statements)

References 29 publications

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“…Notably, this study was undertaken in a state with minimal public insurance support for OAT and history of criminalizing OAT during pregnancy, limiting generalizability [39]. We also note the primary outcome of NOWS was assessed by unblinded Finnegan scoring, a known subjective and biased assessment that has since been replaced by the Eat, Sleep, Console methodology to significantly decrease need for pharmacologic treatment [62].…”

Section: Naltrexonementioning

confidence: 99%

Pharmacotherapy for opioid use disorder in pregnancy

Trammel,

Whitley,

Kelly

2024

Current Opinion in Obstetrics &Amp; Gynecology

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Purpose of review Opioid use disorder (OUD) in pregnancy has significantly in the last decade, impacting 8.2 per 1000 deliveries. OUD carries significant risk of morbidity and mortality for both the birthing person and neonate, but outcomes for both are improved with opioid agonist treatment (OAT). Here, we describe the recommended forms of OAT in pregnancy, updates to the literature, and alternate OAT strategies, and share practical peripartum considerations for patients on OAT. Recent findings Recent studies comparing buprenorphine and methadone have reaffirmed previous findings that buprenorphine is associated with superior outcomes for the neonate, without clear differences in morbidity or mortality for the birthing person. Optimal initiation and dosing of OAT remains unclear, with several recent studies evaluating methods of initiation, as well as a potential role for higher and more rapid dosing in the fentanyl era. Alternative products such as buprenorphine-naloxone and extended-release buprenorphine are of significant research interest, though randomized prospective data are not yet available. Summary Buprenorphine and methadone are standard of care for treatment of OUD during pregnancy, and multiple patient factors impact the optimal choice. Insufficient data exist to recommend alternative agents as a primary strategy currently. All patients with OUD in pregnancy should be counseled regarding OAT. Video http://links.lww.com/COOG/A94

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Section: Naltrexonementioning

confidence: 99%

Pharmacotherapy for opioid use disorder in pregnancy

Trammel,

Whitley,

Kelly

2024

Current Opinion in Obstetrics &Amp; Gynecology

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“…The eat, sleep, console (ESC) approach, developed as a contemporary alternative to the FNAST, focuses on the functional components of withdrawal: whether an infant can eat, sleep and be consoled. Generalizable data to support the efficacy and safety of one approach over the other were lacking until recent results from the ESC-NOW trial demonstrated that the ESC care approach substantially decreased the time until infants were medically ready for discharge and markedly decreased the proportion of infants receiving pharmacologic treatment when compared with usual care with the FNAST …”

Section: Introductionmentioning

confidence: 99%

“…The ESC care approach, guided by the ESC Care Tool, promotes the optimization of nonpharmacologic interventions as first-line treatment and empowers parents and other primary caregivers to participate in the care and medical decision-making for their infants . The benefits of early implementation of individualized nonpharmacologic care during the acute phase of withdrawal have been demonstrated .…”

Section: Introductionmentioning

confidence: 99%

Influence of Eat, Sleep, and Console on Infants Pharmacologically Treated for Opioid Withdrawal

Devlin,

Hu,

Merhar

et al. 2024

JAMA Pediatr

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ImportanceThe function-based eat, sleep, console (ESC) care approach substantially reduces the proportion of infants who receive pharmacologic treatment for neonatal opioid withdrawal syndrome (NOWS). This reduction has led to concerns for increased postnatal opioid exposure in infants who receive pharmacologic treatment. However, the effect of the ESC care approach on hospital outcomes for infants pharmacologically treated for NOWS is currently unknown.ObjectiveTo evaluate differences in opioid exposure and total length of hospital stay (LOS) for pharmacologically treated infants managed with the ESC care approach vs usual care with the Finnegan tool.Design, Setting, and ParticipantsThis post hoc subgroup analysis involved infants pharmacologically treated in ESC-NOW, a stepped-wedge cluster randomized clinical trial conducted at 26 US hospitals. Hospitals maintained pretrial practices for pharmacologic treatment, including opioid type, scheduled opioid dosing, and use of adjuvant medications. Infants were born at 36 weeks’ gestation or later, had evidence of antenatal opioid exposure, and received opioid treatment for NOWS between September 2020 and March 2022. Data were analyzed from November 2022 to January 2024.ExposureOpioid treatment for NOWS and the ESC care approach.Main Outcomes and MeasuresFor each outcome (total opioid exposure, peak opioid dose, time from birth to initiation of first opioid dose, length of opioid treatment, and LOS), we used generalized linear mixed models to adjust for the stepped-wedge design and maternal and infant characteristics.ResultsIn the ESC-NOW trial, 463 of 1305 infants were pharmacologically treated (143/603 [23.7%] in the ESC care approach group and 320/702 [45.6%] in the usual care group). Mean total opioid exposure was lower in the ESC care approach group with an absolute difference of 4.1 morphine milligram equivalents per kilogram (MME/kg) (95% CI, 1.3-7.0) when compared with usual care (4.8 MME/kg vs 8.9 MME/kg, respectively; P = .001). Mean time from birth to initiation of pharmacologic treatment was 22.4 hours (95% CI, 7.1-37.7) longer with the ESC care approach vs usual care (75.4 vs 53.0 hours, respectively; P = .002). No significant difference in mean peak opioid dose was observed between groups (ESC care approach, 0.147 MME/kg, vs usual care, 0.126 MME/kg). The mean length of treatment was 6.3 days shorter (95% CI, 3.0-9.6) in the ESC care approach group vs usual care group (11.8 vs 18.1 days, respectively; P &lt; .001), and mean LOS was 6.2 days shorter (95% CI, 3.0-9.4) with the ESC care approach than with usual care (16.7 vs 22.9 days, respectively; P &lt; .001).Conclusion and RelevanceWhen compared with usual care, the ESC care approach was associated with less opioid exposure and shorter LOS for infants pharmacologically treated for NOWS. The ESC care approach was not associated with a higher peak opioid dose, although pharmacologic treatment was typically initiated later.Trial RegistrationClinicalTrials.gov Identifier: NCT04057820

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“…This includes the potential for NAS/NOWS, which is treatable and short lived when using Eat, Sleep, Console, an intervention that has been shown to drastically reduce length of stay and costs, increase family bonding, and improve many other health outcomes for the whole family. 5 Additionally, health care professionals have a place in challenging current laws calling for reporting based solely on positive drug screens because of the potential for considerable harm from implementing these policies toward the people they are meant to serve. 8 Internists are essential MOUD prescribers and are well equipped to start, continue, and sustain people taking MOUD throughout pregnancy and beyond.…”

mentioning

confidence: 99%

“…Importantly, there are a number of clinical and legal interventions that have the potential to address these barriers and concerns. These include family-centered, evidence-based approaches to treating NAS/NOWS, like Eat, Sleep, Console, and evolving policies that reduce harms toward historically marginalized populations who have been disproportionately affected by reporting based only on positive drug screens. Mandated state reporting of positive drug screens in pregnant people results in ongoing and harmful family control measures that also affect continuing on MOUD or seeking care.…”

mentioning

confidence: 99%

Medication for the Treatment of Opioid Use Disorder in Pregnancy Is Essential

Poland,

Stoltman,

Felton

2024

JAMA Intern Med

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National practice groups and decades of research strongly support treating opioid use disorder (OUD) as a chronic illness and specifically call for the use of evidence-based medications to treat OUD throughout pregnancy and beyond. The criterionstandard medications for OUD (MOUD), including during pregnancy, are buprenorphine (approved by the US Food and Drug Administration in 2002) and methadone (approved by the US Food and Drug Administration to treat OUD in 1972). 1 While evidence suggests that pregnancy may represent a specific window of opportunity to engage individuals in MOUD and that MOUD leads to better outcomes for the maternal-infant dyad, 2 fewer than 1 in 4 individuals with OUD receive treatment in any given month of pregnancy. 3 Improperly treated OUD (eg, not using MOUD or abruptly stopping opioids during pregnancy) has substantial negative effects, increasing morbidity and mortality for the maternalinfant dyad. Research clearly demonstrates that untreated OUD during pregnancy is associated with a number of detrimental effects on the health of the infant (including structural abnormalities and fetal death) and mother (including overdose and maternal death). 2 Despite overwhelming support for the use of MOUD in pregnancy, 1 there are numerous barriers to engaging people in appropriate care, including stigma among prescribing physicians, inadequate training and resources for clinicians, and patient concerns. The primary concerns expressed by patients related to MOUD in pregnancy include the risk of state intervention (eg, loss of custody, criminal proceedings) and perceived negative implications of medication for the infant, including neonatal abstinence syndrome/neonatal opioid withdrawal syndrome (NAS/NOWS). 4 These issues lead to delayed care or avoidance of appropriate treatment and also contribute to negative outcomes for the maternal-infant dyad. Importantly, there are a number of clinical and legal interventions that have the potential to address these barriers and concerns. These include family-centered, evidence-based approaches to treating NAS/NOWS, like Eat, Sleep, Console, 5 and evolving policies that reduce harms toward historically marginalized populations who have been disproportionately affected by reporting based only on positive drug screens. Mandated state reporting of positive drug screens in pregnant people results in ongoing and harmful family control measures that also affect continuing on MOUD or seeking care. Indeed, many of these institutions (eg, departments of child services or child protective services) encourage people to use nonpharmacological management of their OUD and often place contingencies on patients without consultation with health care teams. Health care professionals working with pregnant and postpartum patients who use opioids must understand the Invited Commentary and Editor's Note

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Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal

Cited by 57 publications

References 29 publications

Pharmacotherapy for opioid use disorder in pregnancy

Pharmacotherapy for opioid use disorder in pregnancy

Influence of Eat, Sleep, and Console on Infants Pharmacologically Treated for Opioid Withdrawal

Medication for the Treatment of Opioid Use Disorder in Pregnancy Is Essential

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