Neonatal Abstinence Syndrome Awareness Month 2023: An In-Depth Interview on NAS Treatment and Prevention
Dr. Matthias Muenzer
The number of newborns affected by Neonatal Abstinence Syndrome continues to rise. CleanSlate Centers Massachusetts Senior Medical Director, Dr. Matthias Muenzer, a leading expert in the field, says that understanding the syndrome and intervening with preventative measures is more important than ever.
Warning: This interview discusses infant loss, congenital abnormalities and post-partum issues. Please care for yourself and skip this read if this subject matter may negatively impact your mental health or cause you distress.
If you are currently pregnant and struggling with substance use, we can help. CleanSlate offers special treatment programs tailored to meet your needs during pregnancy.
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Please introduce yourself and describe your path to addiction medicine.
Dr. Muenzer: My name is Matthias Muenzer. I’m a 68-year-old physician who grew up in Germany and in Spain. During my OB/GYN training, I met an American who moved to Germany and then wanted to return home. So I moved to the United States, repeated my residency, and worked as an OB/GYN in the Boston area for over 20 years.
At my previous hospital, I had quite a few patients who were in a methadone program. But a number of pregnant patients who were using substances were not treated, and some very unfortunate cases led me to consider addiction medicine.
Some patients might show up at our hospital half an hour before delivery and the baby would die just after birth. Often, substance users wait until the last second because they want to make sure they have enough heroin or fentanyl on board. Sometimes patients came to the hospital very late in labor and would have complications after birth. We would work so hard to stabilize patients, and then they would check out of the hospital merely hours after birth.
It was stories of this kind, which were just heartbreaking, that led me to consider the advice of a former colleague to switch to addiction medicine.
What is Neonatal Abstinence Syndrome (NAS), and why is it a significant concern for newborns?
Dr. Muenzer: Neonatal Abstinence Syndrome is withdrawal from opioids that the infant experiences after birth, and it’s largely the same as opioid withdrawal in adults. The important thing to know is that babies are not born with addiction. Addiction, by definition, requires a number of things that babies cannot do, like the awareness of taking substances despite knowing it has negative consequences. The babies simply receive the substances in utero from their mothers.
Most of the symptoms of neonatal withdrawal are exactly the same as in adults—anxiety, irritability, restlessness, diarrhea, nausea and vomiting. In babies, it manifests in their crying. There is a specific high-pitched cry which babies in withdrawal have. They also have difficulties nursing, sometimes taking a long time until they can latch on to the breast. They’re not able to sleep like other children, instead waking up frequently. They’re hard to console. When you approach them or touch them, they have jerking movements. Overall they move around a lot more, in the same way as adults in withdrawal have the feeling that they must move their legs all the time. They scratch their elbows and heels because they’re moving around so much.
How do you treat pregnant patients to reduce the risks of NAS?
Dr. Muenzer: Treatment with Suboxone is still by far preferred to having a woman continue to take heroin or nowadays fentanyl during pregnancy. Suboxone is a readily available, prescribed legal substance with a longer half-life. The patient does not have to worry about when she is getting the next dose and often stays away from other people who are using. That can help them avoid other things, like smoking or crack cocaine use, which are also horribly dangerous in pregnancy. These substances can lead to blood pressure spikes that detach the placenta from the uterus, causing bleeding early, with late miscarriage or very early birth.
The patient who is on Suboxone is able to lead a normal life and get regular prenatal care, avoiding many of the psychosocial stresses involved when you are dependent on an illicit substance and focused on how to get the next one. They are able to lead a more regular life with more stability. It makes a very, very big difference.
Is Suboxone [buprenorphine-naloxone] preferred as a treatment for pregnant women?
Dr. Muenzer: Slightly, yes, because women who take Suboxone during pregnancy have a somewhat lower risk of the baby having neonatal abstinence syndrome. The highest level of neonatal abstinence syndrome is illicit drugs, then methadone, then buprenorphine, and then the combination of buprenorphine-naloxone [Suboxone].
Suboxone is still a partial agonist, meaning it attaches to the morphine receptor, but it acts less intensely than heroin, fentanyl and methadone. So it doesn’t eliminate, but it does reduce the risk and severity of NAS.
The general point is that participation in prenatal care is much, much better in women who are in a treatment program as compared to women who are not. The incidence of depression is a lot less. The surveillance of the fetus is much better. And therefore, the ability of the OB/GYN to react to abnormalities in pregnancy is much better.
Another very important difference between illicit users and those in a treatment program is that the baby suffers significantly from the withdrawal of the mother—often more than the mother when she is in withdrawal. Often when the mother just has the early signs of withdrawal, the baby already has significant signs of withdrawal, like changes in heart rate and pooping in the amniotic fluid. That’s another reason why withdrawal should be avoided during pregnancy. Acute withdrawal of the mother can even lead to the death of the fetus.
How are newborns with NAS treated?
Dr. Muenzer: The baby is first assessed according to either one or two scales. The Finnegan scale looks at the classic symptoms that newborns have when they’re withdrawing. The rates and intensities of the symptoms reach a certain score, which allows the physician to determine treatment. The newer alternative, published in 2016, is the “Eat-Sleep-Console” method. The babies are rated according to their ability to eat, how long it takes them to start nursing, whether they’re able to sleep for more than an hour and consoled in under 10 minutes.
The treatment then consists of a combination of morphine, which alleviates withdrawal symptoms, and barbiturates, which prevent seizures. It can be anywhere from the first few days—and occasionally the baby can even go home with the mother after the normal two to four days stay—to sometimes 20-30 days and even up to three or more months in severe cases.
Are there any challenges or barriers that healthcare providers face when treating pregnant women with opioid use disorder?
Dr. Muenzer: Some clinics don’t have immediate availability, or they only use certain methods—only methadone, or only Suboxone. It’s also a matter of knowledge. The physician treating the patient needs to be trained appropriately to best treat pregnant women with opioid use disorder.
It would also be beneficial for OB/GYNs to be informed of best practices in addiction treatment, or establish connections with addiction medicine physicians.
What are some measures that can be taken to prevent NAS?
Dr. Muenzer: It’s always better to prevent. One important step is to provide good birth control to substance users and those in treatment, so that they don’t get pregnant before they’re grounded in recovery. Fortunately, the counseling on birth control now begins with safe, long-acting contraceptives.
Without revealing any identifying details, can you share a success story or a particular case that left a lasting impact on you?
Dr. Muenzer: Yes. I had a patient who had been through multiple pregnancies with me, who had been on Suboxone for two years before her baby, and went from substance user to a complete stable life in long-term recovery. She’s living the American dream now. That was one of the truly encouraging experiences that I’ve had.
Any final thoughts?
Dr. Muenzer: The most important thing is to recognize that substance use is a disease like asthma, hypertension or diabetes. It is not a moral failing. The stigma is tremendously damaging. It causes patients to wait too long to inform their physicians. They’re hesitant to talk about it and they feel shame. They may hide their pregnancies or not go for prenatal care because they’re afraid their children are going to be taken away from them. Removing the stigma is really one of the biggest issues that we have, and one of the most important things we must do.
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