Symptomology Associated with in Utero Exposures to Polysubstance in an Appalachian Population.

Neonatal abstinence syndrome (NAS) is seen at a very high rate at our institution in Huntington, West Virginia, and the majority of exposures are polysubstance in nature. Polysubstance can have different meanings for different regions. At our institution, polysubstance is any combination of opioids, gabapentin, methamphetamine, cocaine, marijuana, benzodiazepines, nicotine or other neuroactive substances with three to four substances being the norm. Rapidly changing combinations of drug use and the lack of literature creates a difficult situation for clinicians who are often reliant on treatment recommendations that lack references or conclusive data supporting the clinical approaches. Elucidating withdrawal symptoms consistent with in utero exposures to particular drug combinations is difficult. Many substances induce similar withdrawal symptoms in neonates and the vast majority of cases present as polysubstance exposure. Standard methodology often leads to a research approach which isolates populations and substance of exposure to determine the individual effects on the neonate. In some drug combinations, like opioid and gabapentin exposure, the substances in concert create symptoms and complications that are not observed with either drug alone. The history of responses to substance use epidemics has been to handle each drug as a separate disease process; this is no longer a viable option. The following is a review of the literature available discussing individual substance withdrawal characteristics in neonates combined with the clinical insight gained at our hospital from treating such high rates of complex polysubstance exposure.