Universal Maternal Drug Testing and Early Identification of Neonatal Abstinence Syndrome (NAS)

1. Neonatal Abstinence Syndrome (NAS)
and Universal Maternal Drug Testing
Presenters:
• Carla S. Saunders, NNP-BC, Advance Practice Coordinator,
Pediatrix Medical Group, Neonatal Nurse Practitioner, East
Tennessee Children’s Hospital
• Scott L. Wexelblatt, MD, Regional Medical Director for Newborn
Services, Cincinnati Children's Hospital Medical Center
Clinical Track
Moderator: Jinhee J. Lee, PharmD, Senior Public Health Advisor,
Division of Pharmacologic Therapies, SAMHSA, and Member,
Rx and Heroin Summit National Advisory Board

2. Disclosures
Carla S. Saunders, NNP-BC; Scott L. Wexelblatt,
MD; and Jinhee J. Lee, PharmD, have disclosed
no relevant, real, or apparent personal or
professional financial relationships with
proprietary entities that produce healthcare
goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Describe current trends in the presentation of NAS.
2. Identify current legislative activities that have an
impact on NAS prevention and treatment.
3. Describe the role of family planning and
contraception for women of child-bearing age who
are in MRT programs.
4. Explain a hospital program that uses universal
maternal drug testing to improve identification of
infants at risk for development of NAS.
5. Outline the justifications for universal maternal drug
testing.

5. Neonatal Abstinence Syndrome:
Changing Trends and Challenges
Carla Worley Saunders APRN, NNP-BC
Neonatal Nurse Practitioner
MEDNAX
At
East Tennessee Children’s Hospital

6. Carla Worley Saunders, APRN, NNP-BC has disclosed no
relevant, real or apparent personal or professional financial
relationships with proprietary entities that produce health care
goods and services.
DISCLOSURE

7. Objectives
• Describe current trends in the presentation of
NAS.
• Identify current legislative activities that have
an impact on NAS prevention and treatment.
• Describe the role of family planning and
contraception for women of child-bearing age
who are in MRT programs

8. Neonatal Abstinence Syndrome
Physical withdrawal in newborns with in-utero drug exposure
*Does not matter if drug it is prescribed, diverted, misused, or illicit*
Multiple symptoms including:
irritability and high-pitched cry, poor sleep, poor feeds, increase tone/tremors,
hypersensitivity, autonomic instability/tachypnea, sneezing, yawning, fever,
sweating, vomiting, cramping, diarrhea, excessive sucking, skin breakdown
Incidence has increased to 5.8 cases per 1000 inpatient births
~ 1 baby every 25minutes
The total US hospital charges for infants with NAS
is > $1.25 billion
100% Preventable

9. 2012 first published data: Patrick et al. JAMA 2012;307:1934-1940
Patrick et al. JAMA 2012;307:1934-1940

10. Incidence of Maternal Opiate Use and NAS
2000-2009
Patrick et al. JAMA 2012;307:1934-1940
Maternal Opiate Use increased x 5 NAS Incidence tripled

11. NAS Incidence and Geographic Distribution
U.S. 2008-12 (Patrick et al, 2015)
Patrick, S. W., Davis, M. M., Lehman, C. U., & Cooper, W. O. (2016). Increasing Incidence and Geographic Distribution of
Neonatal Abstinence Syndrome: United States 2009-2012. Journal of Perinatology, 35(8), 650–655.
highest incidence rate (per 1000 hospital births) of 16.2 (95% CI 12.4 to 18.9 )
(KY,TN,MI,AL)

12. Dramatic Increases in Maternal Opioid Use and Neonatal Abstinence Syndrome. National Institute on Drug Abuse Web site;
https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-
syndrome; September, 2015. Accessed March 11, 2016.
Rate nearly tripled in 3yrs 09-12
previously tripled from 2000-2009
Average LOS 16.9 days
up from 16.4
Average hospital cost $66,700
up from $53,400
1 baby every 25min w/ NAS
up from 1 every hour
21,732 babies in 2012
NAS 2015

13. 2009 2010 2011 2012
Total Charges $730M $1.1B $1.2B $1.5B
MEDICAID
CHARGES
(81%)
$560M $870M $900M $1.2B
Mean hospital charges (U.S.) for discharges with NAS
Total hospital charges (U.S.) for NAS
2000 2009 2012
$39,400 $53,400 $66,700
NAS COST TRENDS
Patrick, S. W. et al. JAMA 2012;307:1934-1940; Partick, S.W. et al. Journal of Perinatology 2015

14. Opioid use in women
of childbearing age
News Release: Opioid painkillers widely prescribed among reproductive age women. Centers for Disease Control
and Prevention Web site; http://www.cdc.gov/media/releases/2015/p0122-pregnancy-opioids.html; January 22,
2015. Accessed March 5, 2016.

15. Substance Use Treatment
among Women of Childbearing Age
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (October 4, 2007).
The NSDUH Report: Substance Use Treatment among Women of Childrearing Age. Rockville, MD.

16. Unintended Pregnancy in U.S.
Fact Sheet: Unintended Pregnancy in the United States. Guttmacher Institute Web site.
https://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html; March, 2016. Accessed March 5, 2016.

17. Unintended Pregnancy
Among All Women & Opioid Abusers
86.3%
49.9%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%100.0%
Opioid-Abusing Women
General Population
Data source: For general population: Tennessee Department of Health. Pregnancy Risk Assessment Monitoring System, 2009
Summary Report. Available at: http://hit.state.tn.us/Reports/HealthResearch/PregancyRisk2009.pdf . For opioid-abusing women:
Heil SH et al. Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment. 2011. March; 40(2): 199-
202.

18. Narcotics and Contraceptive Use:
TennCare Women, CY2011
Demographics
TennCare
Women
Women
Prescribed
Narcotics (>30
days supplied)
Narcotic
Users Rate
per 1,000
Women
Prescribed
Contraceptives
and Narcotics
% of Women on
Narcotics and
Contraceptives
Women
Prescribed
Narcotics
without
Contraceptives
% of Women on
Narcotics
Not on
Contraceptives
All Women 299,989 45,774 152.6 8,400 18% 37,374 82%
15 - 20 88,668 3,450 38.9 1,663 48% 1,787 52%
21 - 24 44,877 5,244 116.9 1,758 34% 3,486 66%
25 - 29 53,583 9,883 184.4 2,368 24% 7,515 76%
30 - 34 48,173 10,504 218.0 1,501 14% 9,003 86%
35 - 39 37,194 9,398 252.7 746 8% 8,652 92%
40 - 44 27,494 7,295 265.3 364 5% 6,931 95%
Data source: Division of Health Care Finance and Administration, Bureau of TennCare.

19. Unintended Pregnancy
Among All Women & Opioid Abusers
• In TN, women with unintended pregnancy:
– More likely to have no preconception counseling (77.7% vs.
55.4%)
– More likely to have short interpregnancy interval (45.0% vs.
15.6%)
– More likely to not take folic acid daily
(82.6% vs. 64.7%)
– More likely to have late or no prenatal care (28.1% vs. 10.9%)
• National sample of opioid-abusing women
– Women with unintended pregnancy 60% more likely
to have used cocaine within past 30 days compared
to women with intended pregnancy
Data source: For Tennessee: Tennessee Department of Health. Pregnancy Risk Assessment Monitoring System, 2009 Summary
Report. Available at: http://hit.state.tn.us/Reports/HealthResearch/PregancyRisk2009.pdf . For opioid-abusing women: Heil SH et al.
Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment. 2011. March; 40(2): 199-202.

21. Epstein et al. 2014
Opioid use among pregnant TN women enrolled
in TennCare
Epstein, R. A., Bobo, W. V., Martin, P. R., Morrow, J. A., Wang, W., Chandrasekhar, R., & Cooper, W. O. (2013). Increasing pregnancy-related use
of prescribed opioid analgesics. Annals of Epidemiology, 23(8), 498–503.

22. Maternal sources of exposures
Pediatrix CDW Tennessee DOH

23. 0
50
100
150
200
250
ETCH Maternal Drug Exposure 2011
Single-
Substance
Exposure:, 122,
34%
Poly-Substance
Exposure:, 234,
66%

24. March, 2013
March, 2016

25. Expanded access to
Buprenorphine may
benefit those in need of
treatment however, to a
baby’s brain it is still an
opiate and they can be
born physically
dependent and
experience withdrawal
and potential long term
effects.

27. To my brain and body, it’s all the
same!!
*It does not matter if drug it is prescribed, diverted, misused, or illicit*

28. 60% Rx
MRT

29. NAS Assessment and Treatment

32. Pediatrix CDW data

34. ETCH Haslam Neonatal Intensive Care Unit
Level III NICU – 60 beds/800 admissions
Nearly 40 % of our NICU admissions primarily for NAS treatment
135 admissions for 2011
283 admissions for 2012
258 admissions for 2013 Over 1300 babies treated for NAS since Nov 2011
265 admissions for 2014 Peak NAS census = 37
323 admissions for 2015 Average daily NAS census = 22
Average Daily Census for NAS babies
1st Quarter
(JAN-MAR)
2nd Quarter
(APR-JUN)
3rd Quarter
(JUL-SEP)
4th Quarter
(OCT-DEC)
2011 8 13 20 18
2012 29 24 29 27
2013 27 22 23 24
2014 24 23 16 17
2015 20 17 22 25

35. Plan
Do
Study
Act
Average LOS decreased
from 34 to 22 days
using Continuous
Quality Improvement
Process (CQI) rapid
cycles
Well defined protocol

36. East Tennessee Children’s Hospital TLKing 3/2016

37. East Tennessee Children’s Hospital TLKing 3/2016

39. 33
45
57
135
283
258 265
323
0
50
100
150
200
250
300
350
2008 2009 2010 2011 2012 2013 2014 2015
ETCH NAS ADMISSIONS 2008-2015
NAS Admissions
Tenfold increase (976%)
in NAS admissions
East Tennessee Children’s Hospital

40. 33 45 57
135
283
258 265
323
5% 8% 10% 21% 37% 34% 36% 38%
637
585
564
646
760 759
743
841
2008 2009 2010 2011 2012 2013 2014 2015
ETCH NAS ADMISSIONS 2008 - 2016
WITH % OF TOTAL NICU ADMISSIONS
NAS admissions Total NICU Admissions
Average 36% NAS admissions past 4yrs
East Tennessee Children’s Hospital

41. 7 4 2
9
2
14
61
0 0
6
0
4 2
13
0 0
15
61
84
144
183
1 2
7
3 3
9
23
0
20
40
60
80
100
120
140
160
180
200
2009 2010 2011 2012 2013 2014 2015
NICU Trends 2009-2015
(all NICU admissions)
NPC LPC Hep-C Cocaine
East Tennessee Children’s Hospital

42. 7
4
2
9
2
14
61
0 0
6
0
4
2
13
0
10
20
30
40
50
60
70
2009 2010 2011 2012 2013 2014 2015
Limited or NO Prenatal Care
NPC LPC
MAY 2014:
Law..Pub.ch
820 Fetal
Assault Law
East Tennessee Children’s Hospital

43. 0 0
15
61
84
144
183
0
20
40
60
80
100
120
140
160
180
200
2009 2010 2011 2012 2013 2014 2015
Hepatitis-C Exposure
(all NICU admissions)
Hep-C
East Tennessee Children’s Hospital

44. 0 0
2.3
8
11
19.3
22
0 0
11
21
32
54
57
0
10
20
30
40
50
60
2009 2010 2011 2012 2013 2014 2015
Hep C exposure: % all NICU admissions vs NAS
admissions
% overall admissions % NAS admissions
East Tennessee Children’s Hospital

45. 1
2
7
3 3
9
23
0
5
10
15
20
25
2009 2010 2011 2012 2013 2014 2015
Cocaine Exposure
(all NICU admissions)
Cocaine
East Tennessee Children’s Hospital

46. Opioid overdose deaths
U.S. 2000-2014
Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths – United States,
2000 – 2014. MMWR Morb Mortal Wkly Rep 2015;64: 1378- 82.
CDC reports 3
out of 4 Heroin
users start
with OPRs

47. Need for family planning in
Substance Abuse Treatment Programs
Connery HS, Albright BB, Rodolico JM. Adolescent substance use and unplanned pregnancy: strategies for risk reduction. Obstet Gynecol Clin
North Am. 2014 Jun; 41(2): 191-203.
• Women = 30-40%
patients in
treatment programs
• Reproductive health
not typically
addressed
• Co-occurring mental
illness, anxiety,
trauma
• Discussions needed
regarding
unintended effects
on baby and impact
to her own
psychological health

48. Fact Sheet: Unintended Pregnancy in the United States. Guttmacher Institute Web site. https://www.guttmacher.org/pubs/FB-Unintended-
Pregnancy-US.html; March, 2016. Accessed March 5, 2016.
60% of U.S.
women at risk for
unintended
pregnancy who
practice
contraception
consistently and
correctly account
for only 5% of
unintended
pregnancies

49. http://www.projectprevention.org/

50. Questions raised:
1) What are the
reproductive rights of
women with
substance use
disorders?
2) Do cash incentives
undermine ability to
make free decisions?
3) How do we assist
women with access
to good reproductive
care and treatment
for their substance
use disorder?

51. Olsen A, Banwell C, Madden A. Contraception, punishment and women who use drugs. BMC Womens Health. 2014 Jan 9;14:5
• Drug use does not =
inability to make
informed health care
choices or to care for
children.
• Women do not need
to be paid to limit or
end their fertility
• Programs to reduce
barriers to obtain free,
non-discriminating
reproductive advise
and parenting support
are better use of
resources.
90 Australian IV drug users interviewed

52. “An ounce of prevention is worth a pound of cure”
Provider education
Safe prescribing practices
Risk assessment (SBIRT)
 CDC Guidelines for
prescribing opiods for
Chronic pain – state level
Use of PDMPs
Registration/regulation
MAT programs “clinics”
Risk assessments as
routine wellness care
Universal drug
testing as routine
wellness care?
Family planning
discussions
Primary Prevention Strategies

53. “An ounce of prevention is worth a pound of cure”
Secondary Prevention
Family planning
discussion early and
frequently during
treatment: risks to self
and baby
Monthly pregnancy tests
and referral to prenatal
care
Contractual information
sharing between
providers
Tertiary Prevention
Evidence based practices
for treatment of
pregnant women with
substance abuse
disorders
Evidence based practices
for treatment of NAS
Trauma informed care
Parenting support
Close follow up

54. Next Steps
Partnership with local treatment center,
health department, and coalitions
Pilot program to bring NAS education into
treatment programs
Pregnancy screening
Access to VLARCS
Early referral to prenatal care
Partnership among providers
Duplicable
3rd party payer support

55. THE END
Contact info: csaunders@etch.com

56. BibliographyCDC. (2015). News Release: Opioid painkillers widely prescribed among reproductive age women. Retrieved March 5, 2016, from
http://www.cdc.gov/media/releases/2015/p0122-pregnancy-opioids.html
Epstein, R. A., Bobo, W. V., Martin, P. R., Morrow, J. A., Wang, W., Chandrasekhar, R., & Cooper, W. O. (2013). Increasing pregnancy-related use
of prescribed opioid analgesics. Annals of Epidemiology, 23(8), 498–503. http://doi.org/10.1016/j.annepidem.2013.05.017
Hall, E. S., Wexelblatt, S. L., Crowley, M., Grow, J. L., Jasin, L. R., Klebanoff, M. a, … Walsh, M. C. (2014). A multicenter cohort study of
treatments and hospital outcomes in neonatal abstinence syndrome. Pediatrics, 134(2), e527–34. http://doi.org/10.1542/peds.2013-4036
Jones, C., Logan, J., Gladden, M., & Bohm, M. (2015). Vital Signs: Demographic and Substance Use Trends Among Heroin Users - United States,
2002-2013. Morbidity and Mortality Weekly Report, 64(26), 719–725.
Mehta, A., Forbes, K. D., & Kuppala, V. S. (2013). Neonatal Abstinence Syndrome Management From Prenatal Counseling to Postdischarge Follow-
up Care: Results of a National Survey. Hospital Pediatrics, 3(4), 317–23. http://doi.org/10.1542/hpeds.2012-0079
Nelson, L., Juurlink, D., & Perrone, J. (2015). Addressing the Opioid Epidemic. JAMA : The Journal of the American Medical Association, 314(14),
1453–4.
Patrick, S. W., Davis, M. M., Lehman, C. U., & Cooper, W. O. (2016). Increasing Incidence and Geographic Distribution of Neonatal Abstinence
Syndrome: United States 2009-2012. Journal of Perinatology, 35(8), 650–655. http://doi.org/10.1038/jp.2015.36.Increasing
Patrick, S. W., Schumacher, R. E., Benneyworth, B. D., Krans, E. E., McAllister, J. M., & Davis, M. M. (2012). Neonatal abstinence syndrome and
associated health care expenditures: United States, 2000-2009. JAMA : The Journal of the American Medical Association, 307(18), 1934–40.
http://doi.org/10.1001/jama.2012.3951
Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, R. M. (2016). Increases in Drug and Opioid Overdose Deaths - United States, 2000-2014.
MMWR. Morbidity and Mortality Weekly Report, 64, 1378–82.
Rutkow, L., Chang, H.-Y., Daubresse, M., Webster, D. W., Stuart, E. A., & Alexander, G. C. (2015). Effect of Florida’s Prescription Drug Monitoring
Program and Pill Mill Laws on Opioid Prescribing and Use. JAMA Internal Medicine, 1–8. http://doi.org/10.1001/jamainternmed.2015.3931
Sarkar, S., & Donn, S. M. (2006). Management of neonatal abstinence syndrome in neonatal intensive care units: a national survey. Journal of
Perinatology : Official Journal of the California Perinatal Association, 26(1), 15–7. http://doi.org/10.1038/sj.jp.7211427
TennCare. (2016). TennCare NAS Data 2014. Retrieved March 9, 2016, from https://www.tn.gov/tenncare/topic/tenncare-neonatal-abstinence-
syndrome-data
Tennessee Department of Health. (2016). Drug Dependent Newborns (Neonatal Abstinence Syndrome) December Update. Retrieved March 5, 2016,
from http://tn.gov/health/article/nas-update-archive
Tolia, V. N., Patrick, S. W., Bennett, M. M., Murthy, K., Sousa, J., Smith, P. B., … Spitzer, A. R. (2015). Increasing Incidence of the Neonatal
Abstinence Syndrome in U.S. Neonatal ICUs. N Engl J Med, April(Online First), 1–9. http://doi.org/10.1056/NEJMsa1500439
White House Office of the Press Secretary. (2016). FACT SHEET: President Obama Proposes $1.1 Billion in New Funding to Address the
Prescription Opioid Abuse and Heroin Use Epidemic. Retrieved from https://www.whitehouse.gov/the-press-office/2016/02/02/president-
obama-proposes-11-billion-new-funding-address-prescription

57. Neonatal Abstinence Syndrome
Scott L. Wexelblatt, MD
Medical Director Regional Newborn Services, Cincinnati Children’s Hospital Medical Center
Assistant Professor, Department of Pediatrics, University of Cincinnati College of Medicine

58. Disclosures
Scott Wexelblatt MD, has disclosed no relevant,
real or apparent personal or professional
financial relationships with proprietary entities
that produce health care goods and services.”

59. Objectives:
• Briefly describe NAS and how we got here.
• National, OH, and Cincinnati specific data.
• Describe how we decided to initiate universal
maternal drug testing, and how we have
implemented this process regionally.
• Describe how we have started to address
hepatitis C on a risk based strategy.

60. What is Neonatal Abstinence Syndrome
• The clinical findings associated with opioid
withdrawal has been termed the neonatal
abstinence syndrome (NAS).
• Among neonates exposed to opioids in utero,
withdrawal signs will develop in 55% to 94%.
• 30-60% will require pharmacologic treatment
• Average hour of onset symptoms: 44(+/-34) in our statewide
study of 994 infants.
PEDIATRICS Vol. 129 No. 2 February 1, 2012 PEDIATRICS Vol. 135, August 2014.

61. What is Neonatal Abstinence Syndrome
• Poor feeding
• Uncoordinated and constant sucking
• Vomiting
• Diarrhea
• Dehydration
• Poor weight gain
• Increased sweating
• Nasal stuffiness
• Fever
• Mottling
• Temperature instability
• Tremors
• Irritability
• Increased Wakefulness
• High Pitched Cry
• Increased Muscle Tone
• Increased Reflexes
• Frequent Yawning
• Seizures
PEDIATRICS Vol. 129 No. 2 February 1, 2012
pp. e540 -e560

63. Rate* of unintentional drug overdose deaths per 100,000
www.cdc.gov/nchs/nvss.htm.
* Per 100,000 population
How did we get here?
State by State Comparison 2008

64. Updated 2010 data rate* of unintentional drug overdose deaths
per 100,000

65. MMWR. Nov. 21, 2014 / 63(46);1095
In 2008, more people died from overdose then
from firearms or motor vehicles in the US.

67. Pregnancy and Opioid use
• Of 112,029 pregnant women in TN, 28% (31,354)
filled more than or equal of 1 opioid prescription
between 2009 and 2011.
• These women that received Rx were more likely to
have depression (5.3% vs 2.7%), anxiety disorder
(4.3% vs 1.6%), and to smoke tobacco (41.8% vs
25.8%) compared to those not prescribed opioids
during pregnancy. (P < .001)
• 65% of infants that developed NAS were exposed
to legally obtained prescriptions.
• Pediatrics Vol. 135 No. 5 May 1, 2015

68. Exposure to prescription opioid analgesics in utero and risk
of neonatal abstinence syndrome
• Records of 290 605 pregnant women filling opioid
prescriptions between 2000 and 2007 via Medicaid.
• Absolute risk of 5.9 per 1000 deliveries
• In a matched analyses, long term prescription opioid use (>30
days) demonstrated a greater risk of NAS compared with short
term use.
• Late use in pregnancy demonstrated a greater risk of NAS
compared with early use.
• (Definition for late use was within 90 days of delivery)
the bmj | BMJ 2015;350:h2102 | doi: 10.1136/bmj.h2102

69. Increasing incidence and geographic distribution of neonatal
abstinence syndrome: United States 2009 to 2012
• Hospital charges for NAS increased from $732 million to $1.5 billion
from 2009 to 2012.
• 81% attributed to state Medicaid programs in 2012.
Patrick. Journal of Perinatology (2015) 35, 650–655

70. ~3 fold increase from 2010 to 2013
~4.5 fold increase from 2001
Sharp increase in heroin 2010

72. Ohio had a 413% increase in unintentional drug
overdose from 1999 to 2013

73. Updated OH data for 2014 with no improvement

74. Ohio Data:
Unintentional Overdose Deaths by Specific Drug

76. 76

77. 77

78. 78

79. 79

80. 80

82. Drug Exposure rate per 1,000 births
(4 fold increase)
Data from delivery hospitals ICD9 codes in Cincinnati area.
16.3
19.4
28.3
40.0
56.7
72.9
69.4
0
10
20
30
40
50
60
70
80
2009 2010 2011 2012 2013 2014 2015*
CINCINNATI REGION
CINCINNATI REGION

83. Drug Exposure rate per 1,000 births
5.7 5.1
8.9 10.9
24.4
36.8 35.8
28.9
36.3
103.9
147.1
187.2
153.6
161.7
28.0
119.2
0
20
40
60
80
100
120
140
160
180
200
2009 2010 2011 2012 2013 2014 2015*
a
b
c
d
e
f
g
h
CINCINNATI REGION

84. Opioid Exposure Rate per 1,000 births
(14 fold increase)
2.4
6.7
7.8
16.4
27.0
34.7 34.4
0
5
10
15
20
25
30
35
40
2009 2010 2011 2012 2013 2014 2015*
CINCINNATI REGION
CINCINNATI REGION

85. Opioid Exposure Rate per 1,000 births
0.9 0.6 0.7
4.5 5.6
11.5
9.86.0 6.3
8.1
30.0
91.1
52.8
83.8
0
10
20
30
40
50
60
70
80
90
100
2009 2010 2011 2012 2013 2014 2015*
a
b
c
d
e
f
g
h
CINCINNATI REGION

86. NAS rate per 1,000 births
Needing pharmacologic treatment.
(~3 fold increase)
4.3
6.5
8.6
7.1
8.1
11.0
11.7
0
2
4
6
8
10
12
14
2009 2010 2011 2012 2013 2014 2015*
CINCINNATI REGION
CINCINNATI REGION

87. NAS rate per 1,000 births
Needing pharmacologic treatment.
1.7 2.1 1.7 1.7
4.5 3.1 3.33.6
5.0
22.7
21.0 21.9
27.2
50.9
0
10
20
30
40
50
60
2009 2010 2011 2012 2013 2014 2015*
a
b
c
d
e
f
g
h
CINCINNATI REGION

88. Universal Testing

89. METHODS OF SCREENING/TESTING
• Maternal Interview Screen
• Maternal Urine Drug Test
• Infant Urine Drug Test
• Meconium Toxicology Test
• Umbilical Cord Toxicology Test

90. Maternal Risk Based Screen
ACOG Committee Opinion 524, May 2012.
Recommends universal screening.
Recommends obtaining consent prior to testing.

91. Maternal Risk Based Screen
Validated for women under 26 years of age.

92. Types of Toxicology Testing
Urine: (Window 1-30 days depending on drug)
Immunoassay:
• Result: Positive or Negative
• Con: False positive with diet/medications.
• Pros: Immediate result
Mass spec:
• Result: Absolute number
• CCHMC: Tests for 47 drugs of abuse on a drop
of urine
• If samples arrive in our lab by 10:30AM then
we report by the end of the day (4-5pm).
Cincinnati Children’s Clinical Mass Spectrometry Laboratory
Phone: 513-636-4344

93. Types of Toxicology Testing
• Meconium:
• Pro:
• Window: Months
• Mass spec is conformation, get absolute value.
• Cons:
• Need to collect meconium with aid of parents.
• Takes 1-3 days to collect sample.
• Takes 3-4 days to get results.
• Umbilical Cord
• Pros:
• Window: Weeks to months
• Mass spec is conformation, get absolute value.
• Can send at time of delivery
• Cons:
• Takes 3-4 days to get result.
• Newer technology, reference ranges not known.

94. Risk Based Screen
Risk Based Screen
Documented, suspected, or acknowledged maternal history of drug use
Insufficient prenatal care, defined as starting care after 12 weeks gestation
Placental abruption
Admission from a justice center
Positive for HIV
Positive for hepatitis B surface antigen
Positive for hepatitis C virus
Maternal history of gonorrhea or syphilis

95. Universal Testing
• We evaluated the efficacy of a universal testing
protocol for all mothers in a community hospital setting
that experienced a three-fold increase in neonatal
abstinence syndrome (NAS) over the past five years.
• In 2012 Mercy Hospital Anderson cared for 1,868
neonates born to 1,874 women of whom 96% were
Caucasian, 52% were married, and 51% had private
insurance

96. Universal testing
Number of Admissions
2,995
Number of Urine
Drug test sent
2,956
Negative Test Result
2,797
Number of Refused Test = 1
Test not done =38
Positive Test Results
159/2,956 (5.4%)

97. Universal testing
•All subjects with positive urine tests were reviewed to determine if there was a
history or suspicion of drug use, insufficient prenatal care, placental abruption,
STDs (HIV, HepB, HepC, GC/Syphilis), or an admission from a justice center,
which would have prompted urine testing using our previous risk-based
screening guidelines.
•We also reviewed the records of infants born to mothers with a positive
toxicology for opiates to determine if an admission to the special care nursery
was required.

98. Universal testing
•5.4% of all mothers had a positive drug test on
admission.
•3.2% of the mothers were positive for opiates.
•20% of the mothers with a positive urine drug
test for opiates had a negative risk based
screen.
•7 of the 19 (37%) infants “discovered” with
universal testing required additional care for
signs and symptoms of NAS.
•23% of the mother’s with a positive drug test
for any drug had a negative risk based screen.
•In this single center study, a traditional risk-
based maternal screening tool had a positive
predictive value of 11% for opioids, and 17.6%
for all drugs.
Positive for Opiates
96/2,956 (3.2%)
Positive for Others
63/2,956 (2.1%)
Positive Risk Based
Screen
77/96 (80%)
Negative Risk Based
Screen
19/96 (20%)
Positive Risk Based
Screen
46/63 (73%)
Negative Risk Based
Screen
17/63 (27%)
Total Number of Positive
tests with a Negative Risk
Based Screen
36/159 (23%)
Number of Negative Risk
based screen infants needing
additional care for signs and
symptoms of NAS
7/19 (37%)
Positive Test Results
159/2,956 (5.4%)

99. Universal Testing
18 hospitals in our region now doing universal testing (2015)
Delivery Service Hospitals
Atrium Medical Center
The Christ Hospital
Dearborn County Hospital
Kettering Health Network
Highland District Hospital
Margaret Mary Hospital
Mercy Health Partners
St Elizabeth Hospital
TriHeatlh
UC Health

100. Universal Testing
• Started Universal Testing on Sept 1st, 2013.
• Encourage consent
• Recommend DAU 13 for mother and infant
due to increase in buprenorphine
availability.
• Send confirmation for denial of use.

101. Admission to Labor
and Delivery
Consent for
universal
maternal
testing?
Send newborn 1st
urine and/or send
umbilical cord
Send maternal
toxicology test
Y
Is maternal
toxicology test
positive?
Is there a history of
illicit drug/opiate
use during
pregnancy?
Routine care
N
1.Send newborn 1st
urine
(initiate process in
delivery room)
2.Send cord or meconium
3.Social Work consult
N
Perinatal Institute Neonatal Abstinence Syndrome Management Process Map
This is a suggested guideline, each hospital may have unique circumstances which requires a different process than suggested
Is drug test + for
other opioid?
Observe for 72 hrs,
initiate Finnegans 6-
24 hrs after birth
and begin non
pharmacological
interventions
Y
Is drug test + for
buprenorphine/
methadone?
Observe for 96 hrs,
initiate Finnegans 6-
24 hrs after birth
and begin non
pharmacological
interventions
Is drug test + for
other drugs?
No Finnegan’s, apply
code:
Cocaine – 760.75
THC – 760.73
Y
N
Are Finnegan
scores ≥ 8x3 or ≥
12x2?
Begin pharmacologic
treatment protocol,
apply NAS code
(779.5)
Schedule clinic appt, call
PCP prior to discharge
Apply code-760.72, call
PCP prior to discharge
N
Y
Y
Y
Missed first
maternal test
Routine care
Y
N N

102. GUTTMACHER INSTITUTE
STATE POLICIES IN BRIEF As of MAY 1, 2015

103. Hepatitis C

104. Number of Hepatitis C exposed infants in Cincinnati Region
Based on ICD9 codes
5.11 per 1,000 births in 2014 compared to 0.56 in 2009

105. Hepatitis C
Updated data through 994 mothers:
• Heroin use: 30% (n=298)
• Hepatitis C rate: 26% (n=257)
Prevention Not Permission
Portsmouth City Health Department

106. Hepatitis C
• Hepatitis C can be transmitted from mother to
child during the pregnancy and birthing process.
• The vast majority of newborns that acquire
perinatal hepatitis C are asymptomatic for the
first 20 years but require close follow-up, as
development of liver fibrosis may occur during
this period.
• Similarly, 2% of newborns that acquire perinatal
hepatitis C can develop cirrhosis within the first
10 years of life.
• Pediatric treatment is available to prevent such
liver damage.

107. Hepatitis C
• About 5% of babies born to mothers with
hepatitis C will acquire the infection from their
mother during the pregnancy and birthing
process.
• If a mother has another viral infection such as
hepatitis B or HIV, the chances of her baby
developing an infection with hepatitis C is
increased to about 10-15%.

108. Hepatitis C
• Health Collaborative Recommendations
• Identification of Risk Based testing:
– Positive Drug Screen Results (exception THC only
substance)
– History IV Drug use
– No prenatal care
– Practitioner request for other reasons such as
physical evidence, sexual partner with history of IV
drug abuse, etc.

109. Hepatitis C
• Follow Up Care:
– Referral to Infectious Disease or GI (mother)
– Provide handout to Mom
– Neonatal Follow up
– Print out information in Discharge Instructions

110. Hepatitis C Treatment Cascade
Yehia et al. PLoS One. 2014; 9(7): e101554.

111. Current Pediatric Clinical Trials

112. Instead of: Try:
Addict Person with a substance use disorder
Person with a serious substance use disorder
Addicted to X Has an X use disorder
Has a serious X use disorder
Has a substance use disorder involving X (if more than one substance is
involved)
Addiction Substance use disorder
Serious substance use disorder
• Note: Addiction is appropriate when quoting findings or research that used the
term or if it is a proper name of an organization. It is also appropriate when
speaking of the disease process that leads to someone developing a substance
use disorder that includes compulsive use (for example: “the field of addiction
medicine” or “the science of addiction”.
Clean Abstinent
Clean Screen Substance-free
Testing negative for a substance use
Dirty Actively using
Positive for substance use
Dirty Screen Testing positive for substance abuse
Drug Habit Substance use disorder
Compulsive or regular substance abuse
Drug/Substance
Abuser
Person with a substance use disorder
Person who uses drugs (if not qualified as a disorder)
Former Addict Person in recovery
Opioid
Replacement
Medication assisted treatment
Medication assisted recovery
Source: White House Office of National Drug Control Policy

114. Neonatal Abstinence Syndrome (NAS)
and Universal Maternal Drug Testing
Presenters:
• Carla S. Saunders, NNP-BC, Advance Practice Coordinator,
Pediatrix Medical Group, Neonatal Nurse Practitioner, East
Tennessee Children’s Hospital
• Scott L. Wexelblatt, MD, Regional Medical Director for Newborn
Services, Cincinnati Children's Hospital Medical Center
Clinical Track
Moderator: Jinhee J. Lee, PharmD, Senior Public Health Advisor,
Division of Pharmacologic Therapies, SAMHSA, and Member,
Rx and Heroin Summit National Advisory Board