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What is an opioid?
Opioids are a drug class that includes heroin, synthetic drugs like fentanyl, and prescription pain relievers (National Institute of Health, n.d.).

Heroin is an illegal substance that is sold and purchased on the streets. It is a highly addictive substance. According to the Centers for Disease Control and Prevention (CDC), 36 people die each day as a result of a heroin overdose (CDC, n.d.).

Because synthetic drugs like fentanyl are more potent than other opioids, they are used to treat severe pain (CDC, n.d.). One application is for advanced cancer pain (CDC, n.d.). Currently, fentanyl is being illegally produced and sold across the country as a recreational drug, exacerbating the opioid epidemic (CDC, n.d.).

Prescription opioids are those that doctors typically use to treat moderate to severe pain (CDC, n.d.). Morphine, oxycodone, and hydrocodone are examples of these medications (CDC, n.d.)

This presentation aims to identify issues involving the opioid epidemic, specifically the effects on neonates.

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What is the problem?
Neonatal abstinence syndrome (NAS).
This happens when the baby is exposed to drugs during pregnancy, most commonly opioids (March of Dimes, n.d.). Once removed from the womb and the source of drug access, the baby experiences withdrawal symptoms.

Who is affected?
Neonatal abstinence syndrome affects babies whose mothers used narcotics frequently or routinely during their pregnancy.

How?
Opioids, antidepressants, barbiturates, and benzodiazepines taken during pregnancy pass through the placenta and are absorbed by the developing fetus (March of Dimes, n.d.). The placenta provides nutrients and oxygen to the baby via the blood that travels through the umbilical cord to the baby.

When?
As previously stated, neonatal abstinence syndrome occurs when a pregnant woman uses narcotics on a regular basis throughout her pregnancy (March of Dimes, n.d.)

Where?
This syndrome can affect newborns anywhere in the United States and around the world. In the United States, the opioid epidemic has become a major issue (CDC, n.d.)

Why?
The use, misuse, and death rate of opioids has increased. The first wave of opioid use began in the 1990s, when prescription opioids increased (CDC,n.d.). When heroin became more prevalent in the United States in 2010, the second wave began. The third wave began with the illicit manufacture of synthetic opioids (CDC, n.d.). With narcotics so easily available, the prevalence of neonatal abstinence syndrome will only rise.

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What the Numbers Reveal
Substance abuse during pregnancy is becoming a major issue in the United States, according to the CDC (CDC, 2016). From 2000 to 2013, the rate of babies born with NAS increased fivefold, with one baby born with NAS every 25 minutes on average (CDC, 2016).

What has led to the opioid epidemic?

In the 1990s, there was concern about undertreating pain (Krans & Patrick, 2016).

Introducing pain as the "fifth vital sign." (Krans & Patrick, 2016).

Pharmaceutical companies are minimizing the addictive potential of opioid pain relievers (Krans & Patrick, 2016). As a result, overprescribing and prescribing for chronic pain rather than acute severe pain has occurred (Krans & Patrick, 2016).

What can be done?

The criminalization of drug use while pregnant (Krans & Patrick, 2016).

While this may deter pregnant women from using narcotics during their pregnancy, removing a parent's parental rights is not always a positive outcome for the child.

We should increase the accessibility and availability of medication-treatment facilities (Krans & Patrick, 2016).

During prenatal visits, patients are screened for drug and alcohol use with consent. (Krans & Patrick, 2016).

Keeping a nonjudgmental attitude in mind.

Assure the patient of privacy (Krans & Patrick, 2016).

Offer resources for those suspected of drug and alcohol abuse during pregnancy.

Improve the care of neonates experiencing neonatal abstinence syndrome (Krans & Patrick, 2016).

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1. Prevent with Education
“The goal of prevention is to delay that on set of first use.” (Rowan, 2017)

- The community must be educated about drug addiction and the risk factors that lead to it. School nurses can begin educating the younger generation by providing resources and ways to help kids make choices to keep them from a life of addiction (Rowan, 2017).

2. Four Pillars Drug Strategy
"Addiction and substance abuse needs to be seen less as a criminal justice issue, but instead as a public health crisis." (Brown, 2017)

- The "four pillars drug strategy," which includes prevention, treatment, harm reduction, and enforcement, can be implemented by community nurses.

Prevention has previously been discussed, with youth education being one aspect.

Support groups are included in the treatment pillar as interventions for those who are already addicted to opioids (Brown, 2017). Creating support groups for only pregnant women to come to and feel free to talk about their struggles and feel supported in remaining sober throughout the pregnancy can help to reduce the number of cases of NAS.

Nurses can also become politically involved in order to secure funding for treatment services such as withdrawal counseling or detox facilities (Brown, 2017).

The harm reduction concept recognizes that abstinence from drugs is the ideal outcome for reducing NAS among newborns, but it also recognizes that transitioning patients from their current drug to a less harmful drug can gradually lead to abstinence (Brown, 2017).

For example, occasional marijuana use is less harmful than IV heroin use on a regular basis.

Nurses should be getting politically involved to ensure that the other three pillars can work together as one unit to end the opioid epidemic and reduce substance use among pregnant women.

3. Break the Stigma
-As nurses, we must examine our own prejudices toward drug users, especially those who work with pregnant women.

To break the stigma, we must first educate ourselves that drug addiction is a disease, not always a choice (Labs, 2017).

Nurses should avoid using negative terminology associated with drug users, such as "junkie," and instead use a more appropriate term associated with a person suffering from a substance use disorder (Labes, 2017).

Raise awareness of the stigma associated with those suffering from substance abuse disorders among our staff, family, friends, and the community (Labes, 2017).

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As of right now, the nurses role is to care for the newborn that is born into this situation. The treatments for NAS include:

Use of medications to reduce withdrawal symptoms. These medications can include morphine, methadone, and buprenorphine (March of Dimes, n.d.).

IV fluids to prevent dehydration due to vomiting and diarrhea  (March of Dimes, n.d.).

Intake of extra calories because of trouble with feeding or growing slowly (March of Dimes, n.d.).

Babies born with NAS are usually very irritable and cry frequently. Interventions used to soothe and comfort the baby include:

Skin-to-skin (March of Dimes, n.d.)

Gentle rocking (March of Dimes, n.d.)

Swaddling (March of Dimes, n.d.)

Dark, quiet room (March of Dimes, n.d.)

Pacifier (March of Dimes, n.d.)

Is this improving or worsening the issue?
These methods improve the withdrawal symptoms of the newborn experiencing NAS, but it does not improve the opioid epidemic situation amongst pregnant women. In order to decrease cases of opioid use during pregnancy, nurses in the out patient setting can educate their patients on the importance of abstinence from narcotic drug use during pregnancy. Nurses can also provide resources for those who are found to have opioids in their system.

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ANALYSIS: Importance of Nurse's Involvement

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ANALYSIS: Importance of Nurse's Involvement

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"Nurses must engage mothers with substance use histories with empathy and nonjudgment, identify and promote maternal agency to care for their infants, and engage and activate mothers to deliver nonpharmacological care during the hospital stay and following discharge." (Shuman et. al, 2020)

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Challenges:
Because nurses are usually not confronted with this issue until they are caring for a baby with neonatal abstinence syndrome, it is difficult to find solutions or become involved in interventions.

When it comes to substance abuse, prevention is everything (Shuman et. al., 2020). Nurses must find ways to engage in the community and provide resources to the obstetric population who are at risk for substance abuse.