Neonatal Opioid Withdrawal Syndrome (NOWS): A Transgenerational Echo of the Opioid Crisis

Abstract

The incidence of neonatal opioid withdrawal syndrome (NOWS) has increased substantially in the setting of the opioid epidemic, a major public health problem in the United States. At present, NOWS has commonly used assessment and treatment protocols, but new protocols have questioned old practices. However, because of limited access to opioid use disorder (OUD) treatment and socioeconomic factors, many pregnant (and postpartum) women with OUD do not receive treatment. The pathophysiology of NOWS is not completely understood, although limited research studies have been conducted in humans and animals to better understand its etiology. Moreover, there is evidence that epigenetic and genetic factors play a role in the development of NOWS, but further study is needed. Animal models have suggested that there are deleterious effects of in utero opioid exposure later in life. Clinical research has revealed the harmful long-term sequelae of NOWS, with respect to cognitive function and childhood development. Many psychiatric disorders begin during adolescence, so as infants born with NOWS approach adolescence, additional clinical and molecular studies are warranted to identify biologic and psychosocial risk factors and long-term effects of NOWS. Additionally, access to specialized OUD treatment for pregnant women must be more readily available in the United States, especially in rural areas.

Intervening with Opioid-Exposed Newborns:

“…The impacts of opioid use on children occur both through prenatal exposure of infants to opioids and through the effects of opioid use and addiction on the mother’s ability to parent. Neonatal abstinence syndrome (NAS), which occurs when infants are exposed to opioids that cross the placental barrier during pregnancy, causes direct neurological impacts but also can disrupt caregiving through symptoms (e.g., high-pitched cry, irritability, difficulty sleeping and soothing) 14 which may make it more difficult for mothers to read their infants’ cues and persist in providing nurturance when infants are distressed. Medication assisted treatment (MAT) is the gold-standard treatment option for pregnant women with opioid use disorder.…”

In utero exposure to morphine leads to sex-specific behavioral alterations that persist into adulthood in cross-fostered mice

“…Characteristic manifestations of NOWS include decreased body weight, high-pitched crying, irritability, tremors, and an inability to be soothed, among many others (Piccotti et al, 2019; Weller, Crist, Reiner, Doyle, & Berrettini, 2020). Reviews and meta-analyses of clinical data have reported infant-adolescent outcomes associated with in utero opioid exposure, including lower scores in neurocognitive and developmental assessments, decreased motor skills, and increased hyperactivity and aggression (Maguire et al, 2016; Minnes, Lang, & Singer, 2011; Nygaard, Slinning, Moe, & Walhovd, 2017; Weller et al, 2020; Yeoh et al, 2019). However, other studies report variability in outcomes among children exposed prenatally to opioids, leading to potential differences in vulnerability and resiliency in these individuals (Labella, Eiden, Tabachnick, Sellers, & Dozier, 2021; Sarfi, Eikemo, Welle-Strand, Muller, & Lehmann, 2021).…”

“…A study of maternal-infant dyads prenatally exposed to opioids reported that roughly 30-60% of newborns were diagnosed with NOWS (Leyenaar et al, 2021; Skumlien, Ibsen, Kesmodel, & Nygaard, 2020), which suggests that a proportion of newborns exposed to opioids in utero may develop a phenotype severe enough to require pharmacological and/or non-pharmacological interventions. Characteristic manifestations of NOWS include decreased body weight, high-pitched crying, irritability, tremors, and an inability to be soothed, among many others (Piccotti et al, 2019; Weller, Crist, Reiner, Doyle, & Berrettini, 2020). Reviews and meta-analyses of clinical data have reported infant-adolescent outcomes associated with in utero opioid exposure, including lower scores in neurocognitive and developmental assessments, decreased motor skills, and increased hyperactivity and aggression (Maguire et al, 2016; Minnes, Lang, & Singer, 2011; Nygaard, Slinning, Moe, & Walhovd, 2017; Weller et al, 2020; Yeoh et al, 2019).…”

Fostering Hope: Comprehensive Accessible Mother-Infant Dyad Care for Neonatal Abstinence (CAIN)

“…Neonatal abstinence syndrome (NAS) occurs in a significant proportion of newborns exposed to substances in utero. More recently, the term neonatal opioid withdrawal syndrome (NOWS) has been introduced, but the term NAS is still used for cases of polysubstance exposure [ 1 ]. In Canada, maternal opiate use in pregnancy has been steadily rising resulting in as many as 1850 newborns born with NAS per year [ 2 , 3 , 4 ].…”