Dr. Johnston of Johns Hopkins University School of Medicine and Chief Medical Officer at Kennedy Krieger Institute has no relevant financial relationships to disclose.)
This article includes discussion of congenital opioid syndrome, and congenital syndromes: narcotics. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
Neonatal abstinence syndrome occurs in over 50% of the neonates born to mothers who were dependent on opioids during the pregnancy. In this article, the author provides a historical background, as well as information on the pathophysiology, clinical spectrum, and management of neonatal abstinence syndrome. The clinical or consulting neurologist will find this information useful in formulating a differential diagnosis when faced with a neonate with signs and symptoms pertaining to CNS/autonomic dysfunction.
• The incidence of neonatal abstinence syndrome following in utero exposure to opioids has increased over the last decade and is related to increased use and abuse of prescription opiates. This has led to increased length of hospital stays and utilization of health care resources.
• Nonpharmacologic and pharmacologic management has not changed the length of hospital stay over the last decade. Standardization of care, which includes standardization of scoring for severity, nonpharmacologic therapy, and pharmacologic therapy as well as strict adherence to treatment protocols, is promising in shortening duration of pharmacologic therapy and length of hospital stay, resulting in decreased cost of hospitalization.
• Studies in genetic and epigenetic factors may shed light on the incidence, severity, and response to therapy in neonatal abstinence syndrome.
Historical note and terminology
Medical use of opium dates back 6000 to 7000 years to Mesopotamian and Egyptian cultures. The word opium in Greek means "poppy juice." Opium has more than 20 alkaloids. Morphine, which was named after Morpheus, the Greek god of dreams, was isolated from opium in 1806 and was followed by the isolation of codeine. In 1822, Thomas De Quincey, in a book titled Confessions of an Opium Eater, first reported narcotic addiction in scientific literature. However, it was not until the end of the century that the concerns regarding adverse effects of maternal narcotic addiction on the fetus were addressed.
Heroin, a semisynthetic narcotic, was manufactured by Bayer Company in 1874 for the treatment of cough and morphine dependency. By 1903, the passage of Pure Food and Drug Act resulted in regulation of narcotics. Methadone was synthesized in Germany and then introduced in the United States in 1947. It was Dole and Nyswander who first reported the use of methadone for the management of heroin addiction (Hoegerman and Schnoll 1991; Jaffe and Martin 1993). In 1998, a National Institute of Health consensus panel recommended methadone maintenance for the management of addiction in pregnant patients (Anonymous 1998).
Opioid narcotics can be divided into natural, semisynthetic and synthetic opioids. Opium, morphine, and codeine are examples of natural opiates derived from the opium-producing poppy, Papaver somniferum. Semisynthetic opioids are derived from opium, and examples of these are heroine, hydromorphine, oxycodone, and buprenorphine. Examples of synthetic opioids are meperidine, fentanyl, methadone, and propoxyphene (Hoegerman and Schnoll 1991).
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