Opioid misuse has reached epidemic proportions in the United States. In addition to medical complications, overdose and death, opioids affect the developing fetus. A specific syndrome, Neonatal Opioid Withdrawal Syndrome (NOWS) describes the features of infants who are withdrawing from in utero exposure (IUE) to opioids. This syndrome involves multiple systems including (1) the central nervous system (high pitched cry, irritability, tremors, increased tone, seizures), (2) the gastrointestinal system (vomiting, poor feeding, uncoordinated sucking, loose stools, failure to thrive), and (3) autonomic dysfunction (sweating, sneezing, temperature instability, yawning, nasal stuffiness) (Sutter, Leeman, His, 2014). Long-term effects and the best ways to manage NOWS are unknown at present. Complicating matters, infants are often exposed to more than one substance. Because of this, the general term, Neonatal Abstinence Syndrome (NAS) is used.
This study reviews 15 years of clinical assessment data from 3598 child welfare involved mothers to understand trends in IUE to opioids over time. The authors found a substantial increase in the rates of IUE to opioids in child-welfare involved mothers with the highest rate of opioid-related exposure among white mothers. Few African American mothers reported opioid-related exposures, but rates of exposure to marijuana were highest in this population. These findings raise important questions about how child welfare involved mothers are assessed and treated, particularly in regard to the IUE of their infants and children. It also highlights the possible importance of racial differences in populations most affected by the opioid epidemic.
Why Study Women Involved in Child Welfare?
Women are at greater risk than men for opioid abuse since they are more likely to be prescribed opioids and to use them for longer periods of time (National Women's health Network, 2018). It has been shown that women involved in the child welfare system experience greater improvement when substance abuse treatment is integrated into their child welfare services. Studying this population could potentially lead to greater resources being directed at prevention and treatment of women and their children affected by opioid abuse. This is the first study that specifically examines IUE to opioids by the biological mothers of children in the child welfare system, helping workers and others who work with these individuals to better understand this population.
The Study
Design
(1)
The Juvenile Court Assessment program in Chicago and suburban Cook County provides drug and alcohol assessments to adults referred by the child welfare system. Record review identified that mothers aged 16 years and older screened between 1998 and 2013 comprised 51.5% of this group and included 3598 mothers.
(2)
At the time of intake, mothers were asked whether any of their children had been exposed to illicit substances during pregnancy. Women who endorsed substance exposure to illicit drugs (opioids, crack/cocaine, marijuana or other substances) provided detailed information regarding the specific substance to which each child was exposed and the age of each child. IUE to a substance was the primary outcome variable in this study.
(3)
Socio-demographic data obtained included race (identified as "white, black or other"), educational attainment, marital status, number of children, age, exposure year and employment status.
(4)
15 years of data were first analyzed to determine rates of opioid use during pregnancy over time. Rates of cocaine and marijuana use were also established so trends in opioid use could be compared. Rate estimates of prenatal exposure for each year and each substance were determined. Trends were also examined by 3 major race categories.
(5)
The sample was then restricted to IUEs from the most recent 5 year period from 2009-2013 so that findings would be reflective of current trends.
Limitations
(1)
This study was conducted utilizing data from a large urban county in the Midwest. These findings may not be generalizable to other regions and populations.
(2)
This study relies on self-report data in contrast to laboratory testing to confirm exposure. It is possible rates of exposure reported are underestimated or inaccurate.
(3)
Information regarding alcohol use or exposure was not obtained since alcohol is a legal substance.
(4)
Timing or amount of exposure to substances in utero is unknown as is the development of NAS or NOWS.
(5)
Race was identified as black, white or other, possibly missing other factors related to ethnicity if this had been asked about in more detail.
General Results
(1)
Between 1998 and 2013, 3598 mothers gave birth to 7659 children, 19% of whom were exposed to at least one substance and 15% exposed to more than one substance.
(2)
The most common exposure was to cocaine (69%) followed by heroin (20%), prescription opioids (11%) and marijuana (11%).
(3)
The majority of the children in this study were black (72%) with equal numbers being white (14%) or another race (14%).
(4)
The rate of IUE to prescription opioids has trended upward in all children from 1.6% in 1998 to 3.3% in 2013 (p = .004). The rate of IUE to prescription opioids rose dramatically more in white children (0% in 1998 to 14% in 2013, p < .001). This was followed by children not identified as black or white (0% in 1998 and 7% in 2013, p < .001). and black children where the numbers remained at 0% (p = .138).
(5)
IUE to heroin rose significantly in white children (1% in 1998 to 14% in 2013, p = 0.007) whereas it decreased significantly in black children (4% in 1998 to 3% in 2013, p = .004) and remained flat in children of another race. Combining these 3 groups led to little change in IUE to heroin for the group as a whole (p = .114).
(6)
The overall rate for IUE to crack/cocaine declined significantly over the study period (p = 0.002) with declines most notable in black children.
(7)
The overall rate of IUE to marijuana increased significantly between 1998 and 2013 (p < .001). Rates in black children increased from 1% in 1998 to 10% in 2013 (p < .001). This trend was similar for other races.
Results from Exposures 2009-2013
(1)
17% of mothers from the large group gave birth from 2009-2013. Their average age was 29 years and the average number of children was 3.6. Approximately 78% were never married, almost 50% had less than a high school education and almost 75% were unemployed.
(2)
About 23% of recent mothers reported at least one IUE to crack/cocaine (43%), marijuana (28%), prescription opioids (20%), or heroin (17%). Co-exposures to cocaine were most prevalent in mothers who reported an IUE to heroin (24%) but less so with prescription opioids (13%).
(3)
Of the 1232 infants born during this period, 18% were exposed to at least one substance, most commonly cocaine (42%), followed by marijuana (29%), prescription opioids (18%) and heroin (16%). Approximately 16% were exposed to more than one substance.
