1. Illicit Drugs and their effects on
fetus/newborn
Presented by: Cynthia Patrello
Inova Fair Oaks NICU-2015
2. Occurs naturally in coca plant- then extracted
and refined. Extracting the alkaloid results in
coca paste then refined to cocaine
hydrochloride.
Crack- processed from cocaine by adding baking
soda and heating it until it forms small pellets. It
is then cooled and filtered to make “rocks” that
are smoked in a pi[e.
Metabolized into numerous compounds:
benzoylecgonine (Urine metabolite), ecgonine,
and ecgonine methyl ester.
3. Normally grown in South America (Andean).
Some grown in India, Africa and Indonesia.
On SPECT exam- the brain looks like mini-
strokes on the surface.
Studies show that after being drug-free for 6
months there is still underactivity in the frontal
and temper-parietal brain regions.
Deficits in attention, concentration, new
learning, visual and verbal memory, word
production
4. With long term use- there are blood flow
deficits and persistent intellectual compromise.
Crack users show a 23% decrease in cerebral
blood flow. Cigarette smoke increased the
percentage to 42%.
Used in combination with other drugs: injected
with heroin (speedball), smoked with PCP (tick)
smoked with marijuana (turbo)
Following a binge the “crash” lasts from 9 hours
-4 days- agitation, depression, insomnia.
Withdrawal lasts 1-3 weeks- paranoia, anxiety.
5. Cocaine in the brain - In the normal communication process, dopamine is released by a
neuron into the synapse, where it can bind with dopamine receptors on neighbouring
neurons. Normally dopamine is then recycled back into the transmitting neuron by a
specialised protein called the dopamine transporter. If cocaine is present, it attaches to the
dopamine transporter and blocks the normal recycling process, resulting in a build-up of
dopamine in the synapse which contributes to the pleasurable effects of cocaine.
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14. The seedpod of the Poppy is dried then
powdered to make opium. Opium contains
several alkaloids one being morphine.
Morphine concentration in opium ranges from
4-21%
Average purity of heroin is 38%
Heroin addicts daily dose is 5-1500mg.
Positive morphine in urine- use within 2-3 days.
Quickly crosses the blood-brain barrier and
converted to morphine, then rapidly binds to
opioid receptors.
15. The limbic system has an abundance of opioid
receptors causing happiness, relaxation,
fearlessness and pain tolerance.
The receptors are flooded with morphine which
produces a sensation of pain-free euphoria and
relaxation. This causes rapid addiction.
After initial rush follows several hours of
“nodding off”
Long term effects cause molecular and
neurochemical brain changes.
16. Heroin is often cut with various substances to
reduce the purity.; sugar, starch, powdered milk,
strychnine and other poisons and drugs such as
Fentanyl.
Sometimes additives won’t dissolve and after
injection can clog blood vessels (to lungs, liver,
kidneys or brain and infecting or even killing
cells in vital organs)
Experience rush within 7-8 seconds IV
5-8 minutes IM and 10-15 min. smoked or
sniffed.
17. Withdrawal symptoms occur if stopped abruptly
or even reduced. Begins within 6-12 hours from
last dose and lasts 5-10 days.
Watery eyes, runny nose. Major withdrawal
peak between 48-72 hours- irritability, diarrhea,
Nausea, vomiting, abdominal cramps, muscle
spasms, bone pain and severe depression.
The chronic user will have skin “sores” on face
and arms that they pick.
19. Amphetamines 10-30mg.
Common Amphetamines Names- Biphetamine,
Dexedrine:
Tolerant individuals take up to 2000mg/d.
Half life can be 7-34 hrs depending on urine ph.
Serum detection 46 hours after ingesting 10mg.
Usually 1-3 days.
20. Methamphetamine- 5-10mg.
Tolerant individuals dose is much higher.
Half-life varies on dose; between 10-30 hours.
Smoking 22mg as base or (“Ice”) detectable in
urine for 60 hours at 300ng/ml.
21. Cocaine- usual dose 20-100mg.
Half life- 20mg- 1 hour; 100 mg- 6 hours.
Serum detection 20mg-4-6 hours; 100mg at 12
hours. Average being 5.1 days in chronic users.
Benzoylecgonine- main metabolite- detected in
urine 1-2 days after IV of 20mg.
Chronic users- using more than 10mg/day-
detected in urine up to 22 days.
22. Opiates: Heroin and Morphine- usual beginning
dose of 10mg. Chronic users 1-2 g/day.
Half life- heroin-2-7 minutes; morphine 2-3
hours.
Detection in urine 11-54 hours.
Associated with severe decrease in blood flow.
Worse brain damage is caused by Heroin.
Opiates
23. Ecstasy (MDMA)- usual dose 50- 100mg.
Half-life 7-8 hours
Detectable in serum- 24 hours; urine 1-3 days
MDMA acronym for
Methylenedioxymethamphetamine.
24. Cannabis-the dose absorbed after smoking
between 5-30mg.
Half life of THC (tetrahydrocannabimol) 30
minutes
Detection in urine- 34 hours with maximum
detection up to 95 days.
25. Fentanyl- Street names: Goodfella, Jackpot,
Murder 8, TNT, Tango.
Injected, smoked, snorted
Detected in urine- 8-24 hours.
26. Oxycodone- Oxycontin, Oxy, O. C. killer
Method of use- oral, nasal, injected
Detected in urine 8-24 hours.
Hydrocodone- Vicodin: Vike, Watson-387
Taken orally.
Detected in urine 1-6 days.
27. Methadone-( Dolophine)
Method of use- oral or injected
Detected in urine 6-12 days.
Buprenorphine (Subutex, Buprenex, Temgesic,
Suboxone)
Method of use- oral or injected.
Detected 1-6 days.
28. Barbiturates- Amytal, Nembutal, Seconal,
Phenobarbital (barbs, reds, red birds, tooles,
yellows, yellow jackets)
Method of Use- oral or injected
Detection in urine- 2-10 days.
Benzodiazepines- Ativan, Halcion, Valium, Xanax
(candy, downers, sleeping pills, tanks)
Method of use- oral, injected
Detection in urine 1-6 weeks.
29. Nicotine- cigarettes, cigars, smokeless tobacco,
snuff, chew
Comes from tobacco plants. The tobacco plants
natural protection from insects is nicotine.
Use of tobacco crops insecticide is being blamed
for killing honey bees.
One drop of the toxin has been proven to be as
lethal as strychnine and in animal studies 3 X
deadlier than arsenic.
Detected in urine 4-30 days.
30. CNS stimulant activating the fight or flight
response resulting in a stimulated high.
Nicotine peak levels within 10 seconds of
inhalation.
Higher serum concentrations in placenta,
amniotic fluid and fetal serum than maternal.
Second hand smoke is more toxic than if you
inhaled the smoke. Contains more than 250
chemicals with at least 69 being cancerous.
31. Thirdhand smoke is the accumulation of second
hand smoke on surfaces such as clothes,
furniture and vehicles that becomes
progressively even more toxic.
It includes lead, arsenic and carbon monoxide.
Can cause breathing problems, learning
disorders and cancer.
Nicotine is also associated with oral facial clefts.
32. Flakka-Made from chemical in the family of bath
salts (Amphetamine)
Bath salts was banned in 2011 however, the
component that makes up Flakka (Alpha-PVP- found
in bath salts) was not.
User feels extreme anxiety, paranoia and
hallucinations. Violent behavior is not uncommon.
Extremely high body temperatures leading to kidney
damage and muscle breakdown.
33. Originated in Russia.
Derivative of codeine.
Highly addictive
Home-based manufacturing with gasoline, paint
thinner or lighter fluid along with hydrochloric
acid and red phosphorus (red tip of matches)
34. 8-10 times more potent than morphine.
Fast –acting
Caustic to veins: ulcerations, gangrene
Short half-life- < 2 hrs.
3 times more toxic
Buyers often think they are purchasing Heroin.
35.
36.
37. Synthetic marijuana
Other names: Skunk, Yucatan Fire, Fake Weed
Banned as Illegal 2012
Physical/Psychological Effects- seizures,
aggressive behavior, paranoia, high blood
pressure, high heart rate, chest pain and
schizophrenia.
38. Capsule or tablet taken orally
Name comes from slang for “molecular”
Crystalline powder form of MDMA
Effects last 3-6 hours.
Usually taken with other drugs-cocaine, meth,
Viagara
Physical effects- increases serotonin, dopamine
and norepinephrine.
This large release influences mood, appetite
and sleep.
39. This large release of serotonin actually depletes
the chemical in the brain- this causes confusion,
depression, drug craving and anxiety.
Heavy use causes attention problems and
memory
High doses can cause hyperthermia- resulting in
kidney or cardiovascular system failure or death.
44. Appear physically and behave normally at birth.
Withdrawal can begin shortly after birth and up
to 2 weeks of age. Average within 72 hours.
Acute symptoms can last several weeks.
Sleeping problems, feeding problems, irritability
and hypertonia may last from 4-6 months.
46. Maternal factors- Send urine toxicology on
mothers with:
No prenatal care or < 5 visits
Hx of drug use/abuse within past year
Hx of positive toxicology screens during
pregnancy and/or previous pregnancy
47. Positive maternal drug abuse through history or
urine toxicology.
Send urine and /or meconium for drug screen
Umbilical cord screen can also be used.
Start NAS screening at 2 hours of life
Assess scoring at least every 4 hours.
Score 30-60 minutes after feeding.
48. Drugs mother used during pregnancy
Timing and amount of last use
Include amount of cigarettes smoked
IF the maternal use of opioids is more than a week
before delivery- the incidence of NAS is decreased
The longer the half life of the drug, the later the
withdrawal occurs. .
I
49. Studies on withdrawal from nicotine have
shown abnormal newborn behavior
immediately after birth up to 5 days with the
findings being more consistent with drug
toxicity as opposed to NAS.
Also associated with a decrease in milk
production, decrease weight gain in infant.
50. Associated with prenatal nicotine exposure is
impulsivity and attention problems
Associated with hyperactivity and negative and
externalizing behaviors which continue into
adult hood showing higher rates of delinquency,
criminal behavior and substance abuse.
Studies have proven abnormalities in learning
and memory, and lower IQ scores.
Children around Second hand smoke are more
prone to headache, dizziness, low energy and
SIDS.
51. The half life of nicotine is 2.5 hours in adults
and 9-11 hours in newborns.
52. Covers 21 symptoms and their degree of
severity.
Sleep- 2 High-pitched at its peak or 3
continuous high-pitched.
Moro Refelx- Score if jitteriness of hands during
or at the end of eliciting Moro Reflex. Score 3 if
jitteriness of hands and/or arms or clonus
Tremors-This is on a scale of increased severity.
Whether disturbed or undisturbed (at rest or
sleep)
53. Increased Muscle Tone-Stiff muscles, resistance
to passive movements.
Excoriation- Skin abrasions ( due to rubbing
against surface) Score ONLY when first appear
or there’s a new area.
Myoclonic jerks- Involuntary, irregular muscle
contractions ( usually only single muscle group)
Generalized convulsions- Usually seen as tonic
extensions of all limbs. Can be limited to one
side.
54. Sweating- only if spontaneous. Not because of
excessive clothing or hot room
Hyperthermia-(37.2-38.3) 99.0-100.9years
Yawning- > 3 yawns within the scoring intervals.
Mottling- If present on chest, arms or legs
Nasal Stuffiness- congestion or mucous visible
Sneezing- > 3 sneezes in scoring interval
Nasal Flaring-repeated flaring without other
respiratory disease.
55. Respiratory rate-Counted for full minute.
IF > 60. Score 2 if involves retractions.
Excessive sucking- Excessive sucking. Increased
rooting.
Poor Feeding- excessive sucking before feeding but
infrequent or uncoordinated during feeding.
Regurgitation- one episode even if remains in
mouth
Loose/watery stools- Loose if curd/seedy
Watery if water ring
56. Restlessness appears first
Mild disturbed tremors
Tremors progress to undisturbed.
High-pitched cry
Hypertonia
Exaggerated Moro reflex
58. Narcotic withdrawal causes significant sleep
disturbances.
Studies show that the narcotics obliterate REM
sleep patterns thus not allowing for the
important deep sleep phase.
With proper treatment, REM and normal sleep
patterns can be restored.
59. Most serious consequence of withdrawal
Occurs in 1-2% heroin-exposed infants
Occurs in up to 7% Methadone exposed
No correlation between amount of drug used
and occurrence of seizure.
Mean age of seizure is 10 days.
These can be generalized seizures or myoclonic
jerks.
Abnormal EEG occurs ONLY during the seizure!
60. There’s abnormal lung compliance and tidal
volume in neonates exposed to heroin or
methadone evidenced by tachypnea.
There is also and increase ph-respiratory
alkalosis during the fist week of life.
The respiratory alkalosis can cause
hypocalcemia and tetany.
61. SIDS is increased by 5-10 times if mothers used
additional drugs with Methadone.
There’s a 2.5%-4% increase in opiate exposed
infant.
Studies have shown a disturbance in sleep
ventilatory patterns and an impaired protective
response to hypoxia and hypercapnia during
sleep.
62. Prior to pharmacologic treatment other
metabolic disorders must be rules out.
Hypocalcemia
Hypomagnesemia
Hypothermia
If the mother has had no prenatal care:
Assess infant for other diseases, IVH and sepsis.
Obtain infant urine for toxicology.
Meconium- screens for drug use over past 20
weeks.
63. Scores of > 8 for 3 consecutive scores
2 consecutive scores >12
This is called the 24 Rule.
Chop.edu
64. If score is =/> 8, increase scoring intervals to
every 2 hr. and continue for 24 hours from the
last total score of 8 or higher.
IF 2 hr scoring is =/< 7 for 24 hours, then 4 hr
scoring resumes.
If after pharmacotherapy discontinued, score is
less than 8 for 3 days, scoring is discontinued.
IF pharmacotherapy D/C scores are consistently
8 or above, scoring should be continued for
following 4 days minimum.
65. Morphine- 0.08-.2mg/dose PO every 3-4 hours.
Dilution is 0.4mg/ml
Advantage- Diminishes bowel motility and
therefore helps loose stools.
Disadvantage- Respiratory depression,
hypotension, urine retention, delayed gastric
emptying.
66. Phenobarbital- Loading doseof 20mg/kg.
If score is >/=….10mg/kg every 12 hours.
Maintenance dose-2-6mg/kg/day for 3-4 days.
67. Absent or diminished reflexes
Persistent mottling
Decreased muscle tone
Diminished response to painful stimuli
Heart rate 80-100
Poor peripheral perfusion
68. Frequent diaper changes
Pacifier
Swaddling
Soft sheets or sheepskin
Prone or right-sidelying position-reduces risk of
aspiration if regurgitation.
Mitts over hands to prevent facial scratching
Decreased environmental stimuli- lights, noise.
69. Need to paint a visual picture of what occurred.
EX. MOB arrived at 2100 smelling of alcohol and
cigarette smoke. Her eyes were red and she
reported not sleeping for days. Her clothing was
soiled with a distinct smell of body odor. She
quickly sat in the chair, never made contact with
the baby or asked questions regarding his care
and fell asleep. I attempted to awaken her but
she fell into a deep sleep snoring. I called
Security who was able to come remove the
mother from the room and get her home safely.
70. She was not appropriate to be in the NICU at this
time due to her condition. I left a VM for the Case
Manager regarding this situation.
Ex. Given by Maria Leathers, SW
