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The neonatal abstinence syndrome refers to a postnatal opioid withdrawal syndrome that can occur in 55 to 94% of newborns whose mothers were addicted to or treated with opioids while pregnant.1,27

 Other terms have also been used to describe the syndrome, including the neonatal withdrawal syndrome,25 the neonatal drug withdrawal syndrome,8 and neonatal withdrawal.27Although the neonatal abstinence syndrome is the term used most frequently in the literature, neonatal withdrawal is probably a more accurate description of the syndrome, since abstinence implies an intention to abstain, and neonates lack the capacity for such an intention.

Some researchers have used a more liberal definition of the neonatal abstinence syndrome that includes exposure to nonopioid substances. This can be problematic because the assessment tools for the neonatal abstinence syndrome were developed for infants exposed to opioids.31However, polysubstance use is common among those who use opioids,10,32 and it is not always possible to attribute the cause of the neonatal abstinence syndrome to exposure to opioids alone.

The inconsistent terminology can lead to challenges in understanding the magnitude and complexity of the syndrome, the presenting signs, and the most effective treatment strategies.17 In this review, we focus on the neonatal abstinence syndrome as a result of opioid exposure, recognizing that many cases involve the use of one or more substances in addition to opioids, which may complicate the evaluation and treatment of the syndrome.33




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Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.


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Question 1 of 1

A 42-year-old African-American man has been diagnosed with hypertension for the past 10 years and treated with medication. One morning, he is found unresponsive by his wife. He is taken to the emergency department and pronounced dead by the physician. An autopsy revealed cardiac hypertrophy and a narrowing of the aorta just distal to the ligamentum arteriosum, with dilation of the intercostal artery's ostia. How could the death have possibly been prevented?



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