Universal Drug Testing at Delivery Aids Infants

Universal maternal drug testing at the time of admission for delivery improves the identification of infants at risk for developing withdrawal syndromes due to illicit drug exposure in utero. The greater-Cincinnati region believes this testing protocol could serve as a model for other communities with a high-prevalence of prescription opiate abuse and with conducive laws.

The switch to universal drug testing began in 2013, following pilot programs, in an attempt to combat a growing epidemic of neonatal abstinence syndrome (NAS), resulting from babies born addicted to drugs. In 2013 alone, according to the Ohio Department of Health, there were nearly five admissions per day for drug-dependent babies. Ohio experienced a 760 percent increase in the number of babies diagnosed with NAS from 2004 to 2013. The department says the average cost to treat a NAS baby is nearly $58,000 per hospitalization (an average length of stay of 15 days), totaling $97 million in 2013. Drug testing enables the hospital to identify and admit drug-exposed babies, who otherwise would likely be sent home before NAS symptoms appear.

"Universal testing is designed to help the family, the mother and the infant," says Scott Wexelblatt, M.D., medical director of regional newborn services at Cincinnati Children's Hospital Medical Center. "One of our main goals with this program is to identify and implement the best practice of care for this group of infants."

Twenty percent of infants exposed to opioids detected by universal screening would not have been identified using risk-based screening, according to results from the program's pilot phase, published in the Journal of Pediatrics in November 2014. The program is currently operational in 18 hospitals in the greater-Cincinnati region, including hospitals in Kentucky and Indiana. According to the Greater Cincinnati Health Council some hospitals have chosen to obtain informed consent for the testing, while others have made it part of their nursing policy.

"Risk-based screening involves profiling and it still won't catch everybody," Wexelblatt tells DTET. "Universal testing is cleaner and actually goes over better ."

Currently, Cincinnati's universal maternal screening is conducted using a urinebased immunoassay, with confirmatory mass spectroscopy-based testing. Current mass-spec confirmatory testing volume at Cincinnati Children's (received from 10 of the 18 participating hospitals) is 20 to 40 samples per day. Confirmatory testing was recently switched from meconium samples to umbilical cord samples, to ease collection for nursing staff. Wexelblatt says they are still fine-tuning the cutoff values in the immunoassay to improve the appropriateness of mass spec testing, which is costly. The hospital is essentially "eating" the cost of the testing (immunoassay ranges from $7 to $13 and mass spec from $50 to $160). While the expense is a "concern," given the flat fee hospitals receive for a delivery, participating hospitals believe it constitutes the "best care" for the infants.

Wexelblatt does field inquiries from hospitals in other areas considering such a program. He says that there are two keys to success. First, universal testing must be implemented regionally; otherwise, he says, word gets out and drug users will go to another hospital to deliver. Secondly, he says, it only works in cities and states that don't use the test results punitively. Unlike in Tennessee, Alabama, and South Carolina where women caught using illegal drugs during pregnancy can be prosecuted, Ohio does not criminally charge women if they test positive. This difference, keeps the universal testing program legal.

In 2001, the U.S. Supreme Court ruled that pregnant women cannot be subject to "warrantless and nonconsensual" searches. In the case Ferguson v. City of Charleston, No. 99-936, women's positive test results were turned over to law enforcement and they were prosecuted for drug offenses and/or child neglect. At the time testing was initiated in South Carolina (1988), the program was driven by an increase in cases of cocaine use among pregnant women. The Supreme Court ruled that drug testing fits in the "closely guarded category of constitutionally permissible suspicionless searches" if there are "protections against the dissemination of the test results to third parties."

Takeaway: More metropolitan areas with a high prevalence of opioid abuse could consider universal maternal drug testing at the time of delivery. This testing strategy, while costly to hospitals, improves care for drug-exposed infants.