The Opioid Crisis on Our Caseloads
Kerry Proctor-Williams, PhD, CCC-SLP
The ASHA Leader, November 2018, Vol. 23, 42-49. 
A speech-language pathologist is called in to help with a newborn who is struggling with feeding. It turns out the infant has neonatal abstinence syndrome (NAS). His feeding problem is just one of many symptoms he experiences as he withdraws from the opioids his mother used during pregnancy.
An audiologist receives a referral to follow up with an infant who did not pass her newborn hearing screening. She has a history of NAS as a result of the opioids and other drugs her mother is addicted to. Fortunately, the screening result was false-positive, and the child has no hearing loss.
A school-based SLP gets an IEP testing request for a student who is lagging behind his peers in his language and literacy skills. It turns out the student had NAS as an infant.
The opioid crisis is not just in the headlines. As these examples demonstrate, it’s showing up in the caseloads and workplaces of audiologists and SLPs. This isn’t surprising given the high rates of opioid use and abuse in the U.S.: In 2015, approximately 91.8 million American adults used opioids, 11.5 million illicitly used or misused opioid pain relievers, 800,000 used heroin, and 1.9 million had an opioid use disorder, based on the National Survey on Drug Use and Health.
Within these numbers are pregnant women: In 2015, an estimated 26,000 pregnant women ages 15–44 illicitly used opioid pain relievers and/or heroin, according to the Center for Behavioral Health Statistics and Quality. Additionally, an unknown number of pregnant women legally use the opioids methadone or buprenorphine (Suboxone or Subutex) during physician-supervised, medication-assisted treatment. These drugs are prescribed to prevent withdrawal symptoms and reduce cravings for opiates, such as heroin and prescription pain killers.
The current best-practice position is that pregnant women should not be weaned from or discontinue opioids suddenly during pregnancy. These actions may cause potential harm to the fetus and increase the likelihood of relapse and uncontrolled drug use by the women. Legitimate programs for pregnant women typically involve weekly monitoring of drug use and management of withdrawal medications, as well as counseling and support to facilitate rehabilitation. As a result of mothers’ monitored or illegal drug use, about 30–50 percent of their infants experience the significant withdrawal symptoms of NAS.
Research about NAS symptoms and detection is well-established, and pharmacological interventions mitigate those symptoms and wean the infant from opioid dependence. Nevertheless, we don’t yet know which drug combinations and maternal health and demographic characteristics predict which infants will get NAS. We also don’t know what the best feeding-intervention strategies or newborn hearing protocols are for these infants.
We do know that after infants recover from NAS, a portion of them will experience cognitive, behavioral, developmental and educational challenges and disabilities. Of these, a disproportionate number (14 percent compared to 10.8 percent in a matched group of children without NAS) will receive speech and language services, indicates a Pediatrics study published this summer and led by the Tennessee Department of Health’s Mary-Margaret Fill (see sources below).
Again, however, our knowledge is sparse: We don’t know what predicts which children will have difficulties post-NAS, what their specific speech and language disorders are, or what interventions work best. Our research on these consequences and encounters is just beginning—and we’re finding that opioid abuse and its effects on children are likely underreported and more serious than we know.
More research is needed to determine how widespread the effects are, how we can boost reporting—and how we can best intervene. In the meantime, research conducted thus far is suggesting ways we can act now.

As a result of mothers’ monitored or illegal drug use, about 30–50 percent of their infants experience the significant withdrawal symptoms of neonatal abstinence syndrome (NAS).

Flagging and treating symptoms
In NAS, opioid receptors in the infant’s brain are suddenly cut off from continual stimulation, triggering abnormal production of neurotransmitters. Among the resulting symptoms are fussiness, gastrointestinal distress and feeding difficulties.
Intervention with feeding problems in the hospital nursery and neonatal intensive care unit (NICU) is often the SLP’s first clinical encounter with the consequences of NAS. For audiologists, that encounter typically follows referrals from newborn hearing screenings. Later, children who experienced NAS as infants may struggle with communication and literacy, among other problems, reappearing on SLPs’ early-intervention and school caseloads.
The number of infants with NAS increased by 300 percent between 2009 and 2013, with an incidence of six cases per 1,000 births in 2013, the last time these statistics were collected (see sources). In other words, every 25 minutes in the U.S., an infant is diagnosed with NAS. More current state-level statistics suggest the problem is worsening. In Tennessee, incidence rose from 0.7 to 13.0 cases between 1999 and 2015 (see sources).

Tip-offs that infants were exposed to opioids prenatally include maternal self-report, unusual infant behavior, and hair, blood or urine samples from the mother and infant. Once medical teams confirm exposure, mother and infant usually remain hospitalized under observation for at least five days.
Depending on the type of opioid and any other drugs the mother used during pregnancy, NAS symptoms may appear between 24 to 72 hours after birth and last eight to more than 30 days, with an average length-of-stay of 19 days. The current standard of care instrument used to assess NAS withdrawal symptoms is the modified form of the Finnegan Neonatal Abstinence Scoring System. It is administered following a feeding, about every three to four hours. Typically, nurses take the primary responsibility of scoring the severity of infants’ symptoms because of their knowledge of the infants and their schedule of infant care. NAS is diagnosed if an infant receives three consecutive high scores, or two consecutive severe scores in three main areas:
  • Central nervous system symptoms, including high-pitched cry duration, a decreased length of sleep after feeding, a hyperactive Moro reflex, tremors, increased muscle tone, myoclonic jerks of limbs, excoriation of tender-skin areas (especially the face, knees, elbows and bottom), and seizures.

  • Metabolic, vasomotor and respiratory symptoms, including sweating, hyperthermia, frequent yawning, mottling, nasal stuffiness, sneezing, nasal flaring and increased respiratory rate (more than 60 breaths a minute).

  • Gastrointestinal disturbances, including excessive sucking, infrequent/uncoordinated suck, reflux or vomiting, and loose or watery stools.

As soon as health care professionals suspect prenatal drug exposure in an infant, they begin non-pharmacological treatment. For example, they use soothing strategies to promote a calm sleep state or to bring the infant to a quiet, alert state for interaction: placing infants in dimly lit quiet rooms with slow and gentle handling, rocking, swaddling and kangaroo (skin-to-skin) care. These infants also need easy access to pacifiers and hands for self-soothing, and arousal from sleep only when necessary.
Once neonatologists confirm NAS, they start pharmacological intervention—morphine or methadone, though phenobarbital or clonidine may be added—to reduce the infant’s discomfort and symptoms while gradually normalizing production of neurotransmitters.
They gradually wean the infant from these drugs as symptoms dissipate. Ideally, mothers room-in with their infants, decreasing the length of pharmacological treatment and hospital stay. This also gives clinicians the chance to help mothers with education, counseling and access to community resources following discharge.

We don’t know what predicts which children post-NAS will have difficulties, what their specific speech and language disorders are, or what interventions work best. Our research on these consequences and encounters is just beginning.

SLPs and feeding
SLPs typically first encounter infants to assess their feeding difficulties symptomatic of NAS. We are not yet sure what proportion of infants with NAS are referred for feeding difficulties to SLPs or even how common it is for SLPs to work with infants with NAS. What’s certain is that feeding infants with NAS is a challenge for nursing staff and mothers.
In a 30-minute feeding period, these infants may truly feed for only 8.5 minutes, spending the rest of the time fussing, crying, resting, sleeping or sedated (see sources below). Compared to non-exposed controls, many opioid-exposed infants show poor feeding efficiency, including more apneic swallows (5.3 percent vs. 0.9 percent), longer sucking bursts (29.3 seconds vs. 19.6 seconds) and fewer sucking bursts (1.6 vs. 2.2 per minute).
They also display more spillage, rejection of the nipple, hiccup, cough and reflux (during 55 percent vs. 38 percent of feeds.) Note that most infants with NAS are full-term infants, so their feeding difficulties likely stem from neurological dysregulation (rather than from immaturity).
For some infants with NAS, the feeding problems can be particularly severe. According to our own retrospective chart review of 149 infants with NAS in Johnson, Tennessee-based Niswonger Children’s Hospital NICU, 25 (17 percent) received direct SLP intervention for swallowing disorders. All received initial naso-gastric tube feedings following a diagnosis of aspiration.
While there are no studies of best practices for feeding infants with NAS to date, discussion with SLPs experienced in NICU care indicate that helpful interventions include:
  • Cue-based feeding for improved coordination of suck-swallow-breath (see “Mom, You Got This”).

  • Identification of environmental triggers for infant irritability, such as light, sound and handling, and of the nonpharmacological strategies that decrease them.

  • Education of mothers, families, caregivers and colleagues about infant cues, feeding, communication, state and interaction that promotes maternal-infant bonding, including breastfeeding.

Clinicians advise breastfeeding NAS-affected infants for their and their mothers’ physical and emotional health. The breastmilk of mothers on physician-supervised medication-assisted treatment (MAT) contains about 1 to 3 percent of the maternal weight-adjusted dose of methadone or buprenorphine. For infants, breastfeeding can help decrease severity of NAS, reduce pharmacological dosage and length, and shorten hospital stays. For mothers, it helps to boost confidence in their caregiving, reduce stress and promote maternal-child bonding. It can also increase mothers’ likelihood of complying with MAT and help keep them from resorting to illicit drug-use (see sources).

Feeding infants with NAS is a challenge for nursing staff and mothers. In a 30-minute feeding period, these infants may truly feed for only 8.5 minutes, spending the rest of the time fussing, crying, resting, sleeping or sedated.

Audiologists and NAS
Audiologists and audiology technicians are also among the first clinicians to see infants with NAS—through newborn hearing screening programs. Infants who are opioid-exposed prenatally are referred to audiologists for a second screening or follow-up at higher-than-normal rates because they failed initial auditory brainstem response (ABR) or automated ABR (AABR) testing in one or both ears. The only study we could find reported referral rates (not mutually exclusive) of 17.1 percent for infants prenatally exposed to opioids and 19.1 percent for infants prenatally exposed to methadone using ABR with a criteria of >30 dB nHL. Follow-up audiological assessment information was not available to determine whether they actually had a hearing loss.
These AABR referral rates are similar to those reported for infants with NAS in our local hospital NICU, which uses AABR at 35dB HL. Compare these high rates for infants with NAS with reported average referral rates of about 2 to 3 percent across all births. (For reference, referral rates for other high-risk infants in the NICU range widely, from 2 to 29 percent across studies; see sources.) These high referral rates for infants with NAS may reflect difficulty testing them, given that they often show extreme fussiness and irritability.
Other factors could contribute to high referral rates. Was testing done in a quiet, individual room or a noisy NICU? Was there middle-ear fluid present from feeding difficulties? Was the infant tested while NAS symptoms were present or following their resolution? Clearly, we need more foundational research to establish best practices for newborn hearing screening in infants with NAS.

Infants who are opioid-exposed prenatally are referred to for a second screening or follow-up by audiologists at higher-than-normal rates.

NAS in schools
When symptoms of NAS resolve, technically the child no longer has NAS. Our interprofessional research group uses the term “children post-NAS” to identify this population; we use “children opioid-exposed” for infants who were prenatally exposed to opioids but did not develop NAS or whose NAS status is unknown.
However, though the label may disappear, effects may not: We have reason for concern about long-term adverse neurodevelopmental outcomes in children post-NAS, according to trends across studies.
Studies indicate that toddlers, preschoolers and school-age children opioid-exposed perform significantly more poorly on cognitive and intelligence testing than non-exposed control groups, though generally within normal limits. At the same time, a few studies report averages more than one standard deviation below test norms (see sources).
Assessments of behavior at school age reveal clinical disorder rates ranging from 26 percent to more than 50 percent for children opioid-exposed (see sources). Their attentional skills are reported to be more similar to those of children with attention deficit hyperactivity disorder (ADHD) than they are to typically developing children.
Two large-scale studies of children post-NAS reveal the impact of such difficulties in school. They point to poor educational outcomes and higher levels of developmental disability than in peer groups matched for demographic characteristics.
The first of these studies, led by Ju Lee Oei and published in 2017 in Pediatrics, examined the national scholastic literacy and numeracy skills of 2,234 third-, fifth- and seventh-grade Australian children post-NAS compared with 602,595 matched peers. They showed significantly lower scores than children without NAS in every grade and in every domain. By the time the children post-NAS were in seventh grade, their scores were lower than the other groups’ scores in fifth grade.
The second study linked Tennessee Medicaid, birth certificate and special education data of 1,815 children post-NAS and 5,441 children without NAS. It revealed that children post-NAS were significantly more likely than the non-NAS matched group to be referred for evaluation and to be both eligible for and receive special education services.
Furthermore, they were significantly more likely to receive speech and language services and special accommodations. Of particular interest to SLPs, a history of NAS increased the odds of receiving speech and language treatment 1.33 times in the 2018 Fill study mentioned earlier. Neither study, however, indicated the severity or types of communication or literacy impairments.
We’ve been surveying school-based SLPs about what they’re seeing. Results are still undergoing analysis and are, as yet, unpublished, but we can report that many SLPs confirm seeing adverse neurodevelopmental outcomes, including receptive-expressive and other language and speech disorders, in clients who are post-NAS. However, there is often inadequate documentation of an infant NAS diagnosis in school records, which can compromise identification of these children:
  • Some SLPs have no or limited knowledge or experience of NAS and report having no children post-NAS on their caseloads. (This suggests some audiologists and SLPs may not realize children post-NAS are on their caseloads.)

  • Children with milder symptomology may not be on speech-language pathology caseloads because multi-tiered systems of support/response-to-intervention eligibility guidelines may allow direct intervention by SLPs only when students present with moderate to profound disorders.

  • Some children post-NAS may have significant difficulties that do not include communication or literacy disorders. Our survey did not capture these children.

Two large-scale studies of children post-NAS point to poor educational outcomes and higher levels of developmental disability than in peer groups.

Need for records and research
As audiologists and SLPs increasingly encounter this population of NAS and post-NAS children, they need accurate medical and school records for initial identification. This may require difficult conversations with mothers, families, caregivers and teachers about sensitive issues related to prenatal drug use during pregnancy. These conversations should occur privately and at the right time—not as part of the IEP.
The conversation should include many of the strategies we use when we break the news of a challenging diagnosis: prepare, be clear, be honest, be respectful, respect feelings, know your own feelings, provide factual information about your concerns, and collaborate with others who have expertise in these conversations, such as psychologists and social workers. It may require SLPs and other special educators to advocate with school administrators for standard requests of this important health documentation as part of school records. Infants and children post-NAS present difficulties that cross boundaries of expertise and require interprofessional collaboration.
It’s important that we expand our knowledge of these children’s feeding and swallowing, communication, literacy, and hearing, particularly given the limited empirical research on the U.S. opioid epidemic. State and local efforts to prevent and treat opioid addiction have reduced the number of infants reported with NAS in our state so far this year; however, other communities are not so fortunate. Particularly in the Midwest, there are reports that opioid addiction is appearing and increasing in regions where numbers were low previously.
Infants with NAS and children post-NAS will continue to appear on audiology and speech-language pathology caseloads for many years to come. Eventually, adults post-NAS also may appear on our caseloads. Our professions urgently need research to understand this population and to develop evidence-based assessment and intervention approaches.
Sarah, Noah and Opioid Addiction: Care Without Stigma

Sarah* was severely addicted to opioids when she became pregnant with Noah*. Both her parents had a history of drug use and jail time, and growing up, Sarah experienced four foster placements and sexual abuse. Eventually her older sister provided a stable home, but she nevertheless dropped out of high school and began to use drugs. Triggered by a miscarriage and an emotionally abusive marriage, Sarah at age 20 was injecting the opioid oxycodone (Roxicodone) 10 times a day. Next followed a divorce, a physically abusive relationship, and a stint in the sex industry.

This is not an unusual story for a young woman addicted to drugs. As noted by Sheigla Murphy and Marsha Rosenbaum in their book “Pregnant Women on Drugs: Combating Stereotypes and Stigma,” many pregnant women who are addicted have experienced poverty and adverse childhood events. Often early exposure to drugs leads to addiction in adolescence or young adulthood. Education is often inconsistent and drop-out rates high

Before she knew she was pregnant with Noah, Sarah used buprenorphine (Subutex) and oxycodone and smoked cigarettes. After realizing her pregnancy, she sought prenatal care and medication-assisted treatment (MAT) through a local pain management clinic, and cut back on her drug use and smoking, taking only buprenorphine as prescribed. As noted by Murphy and Rosenbaum in their book, seeking help and combatting any addiction requires a strong, emotionally compelling reason. Pregnancy and fear of harming a baby can be that motivating event—as it was for Sarah.

When Noah was born, however, he showed symptoms of neonatal abstinence syndrome (NAS) and worsening Finnegan scores—tracking of common neonatal drug-withdrawal symptoms such as tremors, skin excoriation and gastrointestinal problems. Physicians diagnosed him with NAS and administered morphine, which changed to methadone. After having a seizure, Noah also received a short course of phenobarbital. Physicians weaned him gradually from medication.

Sarah attended to him closely during his 20-day stay in the NICU. During this time, through collaboration between the hospital and a community-based nonprofit organization, a counselor made contact with Sarah. She committed to enter the program that was specifically designed for women who have delivered a drug-exposed infant. This initiative to improve transition of care worked for Sarah.

Once home with Noah, she continued taking buprenorphine through physician-monitored MAT, with the goal of getting clean. She took parenting classes and received counseling from social workers and drug-addiction specialists, and participated in a six-month SLP-led mother-baby communication intervention. The clinicians evaluating Noah’s development initially found it in the low–average range in all areas. They noted that the rate and quality of communication between Noah and Sarah was poor and set communication treatment goals for improvement.

The following examples highlight Sarah’s and Noah’s communication progress in the program:

  • Noah’s feedings at 5 months consisted of sitting in a swing in front of the TV with a bottle propped on a pillow. Sarah’s feelings of guilt about her drug use were so great that it was difficult for her to even to look at and hold Noah. By 11 months, however, Sarah fed Noah face-to-face, and the pair were unhurried and interactive.

  • At 5 months, Noah was quiet. His sounds did not include consonants, and vocal turn-taking was rare. At 11 months, he was a communicator, though rates remained low. He combined gaze, gesture and vocalization (including 12 consonants in a variety of syllable shapes), directed his communication to others with a purpose, and produced his first word. Sarah also met her goals as a responsive communication partner. She added language to express his nonverbal communication meaning in words, waited for initiations and responses, and engaged in vocal play. On her own, she made a photo book of his favorite people and toys on her phone.

There are few members of our society who are more marginalized and stigmatized than addicted, pregnant women. Negative interactions with others, especially health care professionals, can result in long-term avoidance of care and extended guilt-ridden periods. Alternatively, one caring health professional can make a difference in a community with adequate and coordinated resources.

Working successfully with mothers who have an opioid addiction and their babies post-NAS is admittedly challenging. But it’s achievable if we partner with addiction counselors, social workers, pediatricians, physical and occupational therapists, and early interventionists as part of a holistic, interprofessional approach. We need to oppose stigmatization and be that caring health professional for the many Sarahs and Noahs out there.

—Kerry Proctor-Williams

*Sarah’s and Noah’s names and a few minor details have been changed to protect their privacy.