TABLE 1.

Strategies and Next Steps

Category	Next Step
Research	Support quality longitudinal studies. Of note, 2 promising initiatives, the ECHO study and the Trans-NIH bBCD study, will direct efforts toward outcomes of longitudinal NAS cohorts by establishing a large cohort of pregnant women and their offspring who will be followed throughout childhood to better understand the impact of specific exposures. Further develop genomics research to understand who is at highest risk for adverse outcomes. Decreasing genomic sequencing costs and innovative approaches to investigate variant function should facilitate discovery of genomic variants and gene pathways associated with differences in maternal, fetal, and placental opioid pharmacokinetics and pharmacodynamics. A better delineation of the risk will allow investigators to (1) establish high-risk genetic profiles so opioid exposure could be limited, (2) establish low-risk genetic profiles and safely wean the mother off MAT without an increased risk of relapse, (3) identify high-risk profiles in pregnant women and modify risk factors such as cigarette smoking and polypharmacy (4) identify high-risk neonates and start low-dose opioid treatment immediately after birth to limit the development and severity of NAS, (5) identify lower risk newborns for early discharge with careful follow-up (a significant cost savings), and (6) combine clinical and demographic variables with genetic profiles and develop graded risk-assessment models to determine the likelihood of addiction after opioid exposure. Deepen an understanding of the role of alcohol, polysubstance, and polypharmacy use on the impact of in utero opioid exposure despite the fact that polysubstance use is extremely common yet currently understudied. Clarify optimal maternal pharmacology, including dosage and alternative medication options, and its impact on the developing fetus. Study the effects of alternative medications such as naltrexone. Study the potential role of detoxification in the treatment of specific subgroups of women. Improve on existing animal models to encompass all stages of brain development and to delineate underlying circuits and mechanisms. Opioids, specifically heroin and morphine, are used in developmental animal models to study the short- and long-term consequences of prenatal exposure.85,86 However, there are challenges with extrapolating the animal studies to humans, including differences in placental transmission,87,88 dose equivalences, and variations in metabolism as well as differences in fetal development.89–93 Include fathers as well as mothers when looking at risk and protective factors. Study appropriate program models to better understand optimal service delivery for families impacted by opiate exposure. Follow outcomes beyond postpartum length of stay. Length of stay is a problematic primary outcome measure that may be influenced by other medical and social issues and may not correlate with long-term outcomes.
Programmatic	Within SUD treatment programs, consider the caregiving role of adults receiving services and offer programming to support positive and healthy parenting. Support family planning and access to contraceptives for women of childbearing age who are experiencing OUD. SUD treatment providers as well as clinicians serving both parents and children should attend to attachment behaviors and positive parenting among mothers and fathers, beginning prenatally and continuing postpartum, to potentially mitigate adverse outcomes. Given the complex needs of many impacted families, make case-management services available to coordinate medical and behavioral health services for parents and children. All neonates with prenatal opioid exposure should access early intervention and screening. Current criteria for early intervention in many states may not enable children with opioid exposure to access these services, especially if developmental issues arise beyond the age of 3 y, when children are transitioned to school services. With additional funding, the Individuals with Disabilities in Education Act, part C would be able to accommodate and sustain early intervention services for children with prenatal opioid exposure. Support models that include peers who can support both parenting and recovery. Provide education about potential childhood developmental and neurocognitive risks to health systems such as early intervention services; Head Start; the Mother, Infant, and Early Childhood Home Visiting Program; day care centers; WIC; and school settings. Expand home-visiting models for early identification of children impacted by opioid exposure and at risk for neurodevelopmental issues. Encourage family-centered approaches and consideration of the needs of all family members, including children, in settings such as family drug courts.
Communication and tracking	Standardize record keeping so that in utero exposures can be communicated across systems. Promote record sharing among providers (prenatal and obstetric, maternal mental health and MAT, and child’s primary care). Develop tracking systems and databases to better monitor outcomes. A national registry of data could include common data elements and terminology, with consensus on variables to track and well-defined, appropriate outcome measures. Outcomes should be value based and should include aspects of healthy child development and school readiness. To the extent possible, information on parents and their mental health and children’s health records should be linked. Promote the use of common definitions of NAS and NOWS. Criteria to diagnosis NAS vary between hospitals, ranging from inclusion of any infant known to be exposed to opioids in utero to only infants requiring pharmacotherapy. The lack of consensus regarding diagnosis complicates tracking efforts.

bBCD, baby Brain Cognitive Development; ECHO, Environmental Influences on Child Health Outcomes; NIH, National Institutes of Health; WIC, Special Supplemental Nutrition Program for Women, Infant and Children.