Symptomology Associated with in Utero Exposures to Polysubstance in an Appalachian Population.

Abstract

Neonatal abstinence syndrome (NAS) is seen at a very high rate at our institution in Huntington, West Virginia, and the majority of exposures are polysubstance in nature. Polysubstance can have different meanings for different regions. At our institution, polysubstance is any combination of opioids, gabapentin, methamphetamine, cocaine, marijuana, benzodiazepines, nicotine or other neuroactive substances with three to four substances being the norm. Rapidly changing combinations of drug use and the lack of literature creates a difficult situation for clinicians who are often reliant on treatment recommendations that lack references or conclusive data supporting the clinical approaches. Elucidating withdrawal symptoms consistent with in utero exposures to particular drug combinations is difficult. Many substances induce similar withdrawal symptoms in neonates and the vast majority of cases present as polysubstance exposure. Standard methodology often leads to a research approach which isolates populations and substance of exposure to determine the individual effects on the neonate. In some drug combinations, like opioid and gabapentin exposure, the substances in concert create symptoms and complications that are not observed with either drug alone. The history of responses to substance use epidemics has been to handle each drug as a separate disease process; this is no longer a viable option. The following is a review of the literature available discussing individual substance withdrawal characteristics in neonates combined with the clinical insight gained at our hospital from treating such high rates of complex polysubstance exposure.

Effects of prenatal opioid exposure on infant sympathetic and parasympathetic nervous system activity

“…However, little is known about the effects of opioid exposure on autonomic nervous system (ANS) regulation specifically, especially beyond the neonatal period. Further, prenatal opioid exposure is frequently accompanied by exposure to non‐opioid substances that are known to be significant teratogens (e.g., tobacco, alcohol, and cocaine; Delano et al., 2013; Lester et al., 2019), but many studies examining opioid exposure fail to account for polysubstance exposure. Polysubstance exposure (i.e., exposure to more than one substance) has been associated with worse outcomes for neonates (Choo et al., 2004; Jansson, Velez, McConnell, Spencer, Tuten, Jones, Rios, et al., 2017), infants (Conradt et al., 2013), children (Conradt et al., 2014), and adolescents (Nygaard et al., 2017) than single substance exposure (opioid or non‐opioid).…”

Outcome reporting in neonates experiencing withdrawal following opioid exposure in pregnancy: a systematic review

“…The later, more specific definition has recently been adopted and may not be reflected in previously published reports. As polysubstance exposures during pregnancy are becoming more prevalent, reportedly as high as 65% in one study [11] and even higher with the inclusion of alcohol and tobacco, NAS is becoming an increasingly complex syndrome with less predictable time of onset, severity and response to pharmacologic therapy [12,13]. From the clinical perspective, there has been a paradigm shift in infant assessment and treatment initiation (using thresholds evaluated by subjective features of withdrawal to using the Eat, Sleep, Console method) [14] and the emergence of novel pharmacokinetic-and pharmacodynamic-based dosing protocols [15].…”