Effects on Neonatal Abstinence Syndrome of Parental Caregivers' Ability to Leave the Postpartum Unit During the COVID-19 Pandemic.

OBJECTIVE: To determine if a policy change that limited the ability of parental caregivers to leave the postpartum unit during the COVID-19 pandemic influenced neonatal abstinence syndrome (NAS) scores, admissions to the NICU for NAS treatment, and length of stay (LOS) on the nursing unit. DESIGN: Retrospective chart review. SETTING: /Local Problem: During the pandemic, a change in policy limited parental caregivers from leaving the nursing unit. PARTICIPANTS: Neonates being screened for NAS during the period before the policy change from April 2, 2019, through April 1, 2020 (n = 44), and the period after the policy change (n = 23) from April 2, 2020, to April 1, 2021. MEASUREMENTS: Levene's test was used to determine homogeneity of variance before independent t tests on mean NAS scores and LOS across groups. A linear mixed-effects model tested differences in NAS scores, accounting for time and group. Chi-square tests determined differences in the number of neonates transferred to the NICU across groups. RESULTS: No differences between group variables were found, with the exception of feeding type and cocaine/cannabinoid use (p < .05). No significant differences were found in mean NAS scores (p = .96), LOS (p = .77) or NAS scores accounting for time and between groups (p = .069). Transfers to the NICU in the pre-policy change group were significantly greater (p = .05). CONCLUSION: Although no decrease was observed for mean NAS scores and LOS of the neonates, a decrease in transfers to the NICU for pharmacologic treatment for NAS was observed. Further research is required to determine casual relationships for the decrease in NICU transfers.

Neonatal abstinence syndrome hospitalizations in Canada: a descriptive study.

OBJECTIVE: The objective of this paper is to describe the trend of newborn hospitalizations with neonatal abstinence syndrome (NAS) in Canada, between 2010 and 2020, and to examine severity indicators for these hospitalizations. METHODS: National hospitalization data (excluding Quebec) from the Canadian Institute for Health Information's Discharge Abstract Database, from January 2010 to March 2021, and Statistics Canada's Vital Statistics Birth Database were used. Analyses were performed to examine NAS hospitalizations by year and quarter, and by severity indicators of length of stay, Special Care Unit admission and status upon discharge. Severity indicators were further stratified by gestational age at birth. RESULTS: An increasing number and rate of NAS hospitalizations in Canada between 2010 (n = 1013, 3.5 per 1000 live births) and 2020 (n = 1755, 6.3 per 1000 live births) were identified. A seasonal pattern was observed, where rates of NAS were lowest from April to June and highest from October to March. Mean length of stay in acute inpatient care was approximately 15 days and 71% of NAS hospitalizations were admitted to the Special Care Unit. Hospitalizations for pre-term births with NAS had longer durations and greater rates of Special Care Unit admissions compared to term births with NAS. CONCLUSION: The number and rate of NAS hospitalizations in Canada increased during the study, and some infants required a significant amount of specialized healthcare. Additional research is required to determine what supports and education for pregnant people can reduce the incidence of NAS hospitalizations.

RéSUMé: OBJECTIF: Le présent article a pour but de décrire la tendance des hospitalisations de nouveau-nés atteints du syndrome d'abstinence néonatale (SAN) au Canada, entre 2010 et 2020, et d'examiner les indicateurs de gravité de ces hospitalisations. MéTHODE: Les données nationales sur les hospitalisations (à l'exclusion du Québec) provenant de la base de données sur les congés des patients de l'Institut canadien d'information sur la santé, de janvier 2010 à mars 2021, ainsi que la base de données sur les naissances des statistiques de l'état civil de Statistique Canada ont été utilisées. Des analyses ont été réalisées pour examiner les hospitalisations liées au SAN par année et par trimestre, et par indicateurs de gravité de la durée du séjour, de l'admission dans une unité de soins spéciaux et de l'état à la sortie de l'hôpital. Les indicateurs de gravité ont en outre été stratifiés en fonction de l'âge gestationnel à la naissance. RéSULTATS: Un nombre et un taux croissants d'hospitalisations liées au SAN au Canada entre 2010 (n=1 013, 3,5 pour 1 000 naissances vivantes) et 2020 (n=1 755, 6,3 pour 1 000 naissances vivantes) ont été identifiés. Une tendance saisonnière a été observée, où les taux de SAN étaient les plus bas d'avril à juin et les plus élevés d'octobre à mars. La durée moyenne du séjour en soins de courte durée était d'environ 15 jours et 71 % des hospitalisations liées au SAN ont été admises à l'unité de soins spéciaux. Les hospitalisations pour les accouchements prématurés de nouveau-nés atteints du SAN avaient des durées plus longues et des taux plus élevés d'admissions dans des unités de soins spéciaux par rapport aux naissances à terme de nouveau-nés atteints du SAN. CONCLUSION: Le nombre et le taux d'hospitalisations liées au SAN au Canada ont augmenté au cours de l'étude, et certains nourrissons nécessitent une quantité importante de soins spécialisés. Des recherches supplémentaires sont nécessaires pour déterminer quels soutiens et quelle éducation pour les personnes enceintes peuvent réduire l'incidence des hospitalisations liées au SAN.

Clinical applications of transcutaneous auricular neurostimulation for opioid use disorder and pain

Symposium title: Addressing chronic pain and the opioid epidemic using auricular neuromodulation Symposium description: Our proposed symposium integrates a diverse group of scientist and clinician experts (Drs. Cunningham, Wilkes, Khodaparast, Badran) who have committed to exploring the anti-nociceptive and opioid sparing effects of auricular neuromodulation to progress toward non-opioid interventions for chronic pain and opioid use disorders. The demand for chronic pain therapies has increased at an unprecedented rate over the last several decades, contributing in part to a surge in prescription and illicit opioid demand. Countless patients were escalated to prolonged, high-dose opioid regimens over years of treatment. By 2014, 5.4% of U.S. adults were estimated to use prescription opioids on a long-term basis. As the harms of opioid proliferation became increasingly clear, a dramatic paradigm shift occurred in which these drugs are now perceived as more dangerous than beneficial for chronic pain. New clinical guidelines highlight the risks of high-dose regimens as well as the limited benefits, particularly insufficient analgesia and hyperalgesia, associated with long-term use. According to this new perspective, the preferred therapeutic modality for many patients is to safely taper, or even completely stop, using opioids. Transcutaneous auricular neurostimulation (tAN) is a novel therapeutic paradigm that includes stimulation of both the auricular branch of the vagus nerve and auriculotemporal nerve (branch of trigeminal). tAN therapy results in clinically significant reductions in opioid withdrawal symptoms associated with opioid detoxification and tapering. Either adjunctive vagal or trigeminal stimulation modulates pain transmission suggesting overlapping common effector pathways, possibly targeting the endogenous opioid system, which could lead to a synergistic therapeutic benefit for pain. This symposium will explore the scientific basis for this hypothesis across targeted and interconnected topics, including fundamental neuropharmacological mechanisms underlying pain and opioids, clinical challenges of tapering opioids, managing opioid withdrawal symptoms with tAN, and the prospects for tAN to deliver a safe alternative treatment option for pain disorders. The United States is experiencing an epidemic for prescription and non-prescription opioids, which have continued to rise since the 1990s. During 2015, approximately 2.1 million people were severely dependent on prescription opioids, and 513,000 on heroin. In 2020, the Centers for Disease Control reported 93,331 substance use overdose deaths. The continuing increase in opioid-related deaths from 2015 (18%) to 2020 (60%) is partly attributed to the mental health crisis during the Covid-19 pandemic. Aside from pain mitigation, individuals with opioid use disorder (OUD) may be motivated to continue drug-seeking by both the positive reinforcement of the euphoric effects of opioids and the negative reinforcement of opioid withdrawal symptoms due to cessation. Alternative approaches for OUD are a major priority for government agencies given the substantial impact on health, social, and economic welfare. Transcutaneous auricular neurostimulation (tAN) is a non-invasive form of vagus and trigeminal neuromodulation that was recently proven to be an efficacious non-pharmacologic based treatment for reducing opioid withdrawal symptoms. In 2021, tAN therapy received FDA clearance as an adjunctive treatment for opioid withdrawal symptoms in adults. tAN therapy was also proven safe and effective in reducing symptoms of neonatal opioid withdrawal syndrome (NOWS) in neonates. tAN as an adjuvant was safe, well-tolerated, while facilitating the successful rapid weaning of oral morphine and decreasing length of stay in the neonatal ICU. Based on these preliminary findings, tAN therapy is currently in two NIH-funded pivotal clinical trials to: 1) evaluate the long-term effects of tAN on opioid use relapse prevention and cravings in adults with OUD, and 2) determine f tAN therapy can reduce withdrawal symptoms and reduce morphine length of treatment for neonates with NOWS. Lastly, we will explore how tAN could be utilized as neuromodulatory approach for opioid sparing, and ultimately pain mitigation. Research Category and Technology and Methods Clinical Research: 12. Vagus Nerve Stimulation (VNS) Keywords: Vagus Nerve Stimulation, Opioid Use Disorder, Pain, NeurostimulationCopyright © 2023

Low Treatment Fidelity as an Indication to Switch Interventions: Pivoting From Child-Parent Psychotherapy to Parent-Child Interaction Therapy for Early Childhood Trauma

Young children who experience trauma and adverse experiences are at an increased risk of developing an insecure attachment style as well as negative physical and mental health problems. These can include internalizing and externalizing behavioral problems, developmental delay, emotional dysregulation, and aggression. Several evidence-based interventions exist to treat young children with symptoms related to trauma, each with different foundational theories. This article presents the case of a 4-year-old boy with posttraumatic stress disorder who was in the middle of a legal fight between caregivers and transitioning between caregivers' homes. Initially, therapy began with Child-Parent Psychotherapy to address caregivers' first concerns. Later, the therapeutical approach was switched to Parent-Child Interaction Therapy due to difficulty with treatment fidelity related to caregivers' symptoms and conflict. This case demonstrates great improvement in treatment fidelity and subsequently problem behaviors after switching to an intervention that allowed to address behavior management shortcomings in a family with ongoing conflict.Copyright © The Author(s) 2022.

Impact of Coronavirus Disease-2019 on Hospital Care for Neonatal Opioid Withdrawal Syndrome.

OBJECTIVE: To compare prenatal exposures, hospital care processes, and hospitalization outcomes for opioid-exposed newborns before and during the coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: In this multicenter retrospective analysis, data were collected from 19 Massachusetts hospitals, including 5 academic and 14 community hospitals. The pre-COVID-19 cohort was defined as births occurring during March 1, 2019-February 28, 2020, and the COVID-19 cohort was defined as births occurring during March 1, 2020-December 31, 2020. Opioid-exposed newborns born at ≥35 weeks of gestation were included. Differences in prenatal substance exposures, hospital care processes, and neonatal opioid withdrawal syndrome (NOWS) outcomes, including pharmacologic treatment for NOWS (PharmTx), length of stay (LOS), and as-needed (prn) treatment failure rates, were evaluated. RESULTS: There were 663 opioid-exposed newborns in the pre-COVID-19 group and 476 in the COVID-19 group. No between-group differences were seen in prenatal substance exposures or the need for PharmTx. Compared with the pre-COVID-19 group, in the COVID-19 group there was less rooming-in after maternal discharge (53.8% vs 63.0%; P = .001) and less care in the pediatric unit setting (23.5% vs 25.3%; P = .001), longer LOS (adjusted risk ratio, 1.04; 95% CI, 1.01-1.08), and a higher rate of breast milk receipt at discharge (aOR, 2.03; 95% CI, 1.22-3.39). Within the subset of academic centers, more infants failed prn treatment in the COVID-19 group (53.8% vs 26.5%, P = .02; aOR, 3.77; 95% CI, 0.98-14.5). CONCLUSIONS: Among the hospitals in our collaborative, hospital processes for NOWS, including care setting, rooming-in, and LOS were negatively impacted in the COVID-19 group, particularly in academic medical centers.

Informing the Development of a Standardized Clinical Definition of Neonatal Abstinence Syndrome: Protocol for a Modified-Delphi Expert Panel.

BACKGROUND: Neonatal abstinence syndrome (NAS) is a postnatal withdrawal syndrome that most commonly results from prenatal opioid exposure. Every 15 minutes, an infant is born in the United States with signs of NAS. The field lacks a standardized clinical definition of NAS, complicating discussions on programmatic and policy development to support opioid-exposed mothers and infants. OBJECTIVE: The goal of this paper is to describe a protocol for a systematic expert panel process to inform the development of a clinical definition of NAS. METHODS: We will conduct two three-round online modified-Delphi panels using the ExpertLens system and will follow the recommendations for Conducting and REporting of DElphi Studies (CREDES). One panel will focus on developing key components of a clinical definition of NAS, and the second panel will focus on neonatal opioid withdrawal syndrome (NOWS), which is a term that has come into use to differentiate opioid-exposed infants from infants exposed to other substances in utero. However, there is lack of agreement on the precise clinical definition of NOWS and how it is distinct from or overlaps with NAS. Each panel will complete two rating rounds and a discussion round using a similar protocol. We will analyze all rating data descriptively and determine the presence of agreement within and between the two panels. We will also perform thematic analysis of the qualitative comments to contextualize the panel findings. RESULTS: The panels were convened between October 29 and December 17, 2020. Their results were disseminated and discussed at a national conference on NAS that took place on March 17-18, 2021. CONCLUSIONS: A standardized clinical definition of NAS will help to better characterize NAS incidence and to design effective clinical, public health, and policy interventions to support opioid-exposed mother-infant dyads. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/25387.