The innocent victims_nas_final

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Clinical Track, National Rx Drug Abuse Summit, April 2-4, 2013. The Innocent Victims: Neonatal Abstinence Syndrome (NAS) presentation by Dr. Michael Hokenson and Carla Saunders

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The innocent victims_nas_final

  1. 1. The  Innocent  Vic,ms:  Neonatal   Abs,nence  Syndrome   Michael  Hokenson,  MD   Assistant  Professor  of  Pediatrics;   Division  of  Neonatology   Carla  Saunders,  NNP-­‐BC   Advanced  Prac@ce  Coordinator,  East   Tennessee  Children’s  Hospital  
  2. 2. Learning  Objec,ves  •   Iden@fy  the  scope  of  babies  affected  by  NAS   with  sta@s@cs  and  research.  •   Evaluate  treatment  programs  around  the   country  that  work  to  care  for  babies  with  NAS.  •   Build  solu@ons  for  clinicians  to  treat  babies   with  NAS.  
  3. 3. Disclosure  Statement  •  Michael  Hokenson  has  no  financial   rela@onships  with  proprietary  en@@es  that   produce  health  care  goods  and  services.    •  Carla  Saunders  has  no  financial  rela@onships   with  proprietary  en@@es  that  produce  health   care  goods  and  services.  An  off-­‐label   discussion  will  take  place.  
  4. 4. Background  •  Despite  growing  knowledge,  NAS  con@nues  to   challenge  us   –  Es@mated  4.5%  of  mothers  14  to  45  yrs/old  use   illicit  drugs     –  ORen  overlap  with  medica@ons  for  chronic  pain   and  mental  illness   –  50-­‐90%  of  neonates  exposed  to  heroin  in  utero   may  develop  signs  of  withdrawal  1   •  Signs/Symptoms  may  be  non-­‐specific   1.  Schuckit  Marc  A.  Opioid  drug  abuse  and  dependence.  Harrisons  Principles  of  Internal   Medicine.  17th  edn,  McGraw-­‐Hill:  New  York,  2008  
  5. 5. Challenges  •  The  number  of  infants  coded  as  (NAS)  at  d/c   are  on  the  rise   –  Na@onally   •  1995-­‐  7,654  infants   •  2008-­‐  11,937  infants   –  In  Florida;   •  1995-­‐  0.4/1000  live  births   •  2008-­‐  4.4/1000  live  births   –  Possibly  increased  awareness,  but  also   prescrip@on  pain  relief  2   2.  Kellogg  A,  Rose  CH,  Harms  RH,  Watson  WJ  .  Current  trends  in  narco@c  use   in  pregnancy  and  neonatal  outcomes.  Am  J  Obstet  Gynecol.  2011;204:259  
  6. 6. Clinical  Presenta,on  •  A  wide  variety  of  drugs  in  utero  may  have  an   effect  on  infant  •  Overlap  between  acute  effect  and  withdrawal   of  substance  •  The  classic  findings  associated  with  opioid   withdrawal  are  coined  (NAS)  
  7. 7. Clinical  Presenta,on  •  Infants  exposed  to  opioids  in  utero   –  Anywhere  from  55-­‐94%  may  exhibit  signs  of   withdrawal  3  •  Infants  may  also  display  signs  of  withdrawal  if   exposed  to:   –  Benzodiazepines   –  Barbiturates   –  Alcohol   3.  Fricker  HS,  Segal  S  .  Narco@c  addic@on,  pregnancy,  and  the  newborn.  Am  J  Dis   Child.  1978;132(4):360–366  
  8. 8. Clinical  Presenta,on  •  Signs  and  symptoms   •  Narco@cs  are  s@ll  the   vary  in  each  infant   most  frequent  cause   –  Will  depend  on  specific   and  include:   maternal  drug(s)   –  Heroin   –  Severity  of  withdrawal  may   –  Methadone   not  correlate  with  dose  or   –  Morphine   dura@on  of  exposure   –  Oxycodone   –  Codeine   –  Buprenorphine  
  9. 9. Clinical  Presenta,on  •  Narco@cs  and  Barbiturates   –  The  @me  frame  for  signs  of  withdrawal  from  narco@cs   may  vary  greatly   •  May  be  present  at  birth  and  peak  at  3  to  4  days   •  May  not  appear  for  up  to  two  weeks   •  Subacute  withdrawal  may  occur  for  4  to  6  months   •  Neurologic  irritability  with  abnormal  Moro  has  been   reported  at  7  and  8  months  of  age  
  10. 10. Clinical  Presenta,on  •  Many  systems  can  be   •  Common  signs  include:   affected   –  Hypertonia  •  The  most  common  are:   –  Tremors   –  CNS   –  Hyperreflexia   –  Gastrointes@nal   –  High-­‐pitched  cry   –  Autonomic  nervous   –  Sleep  disturbances   system   –  Occasionally  seizures  
  11. 11. Clinical  Presenta,on  •  Autonomic  dysfunc@on   •  GI  symptoms  may   may  include:   include:   –  Swea@ng   –  Diarrhea   –  Low  grade  fever   –  Vomi@ng   –  Nasal  conges@on   –  Poor  feeding   –  Sneezing   –  Poor  swallowing   –  Yawning   –  Failure  to  thrive   –  Skin  mokling   •  Respiratory  signs  may  also   be  present   –  Tachypnea   –  Apnea  
  12. 12. S,mulants  •  Methamphetamine  and  cocaine  are  less  common  causes   –  Withdrawal  signs    have  been  observed  in  as  few  as  4%  of   infants     –  Tend  to  be  much  less  severe  than  seen  in  opioid  exposed   infants   –  Generally,  only  6%  of  infants  exposed  to  cocaine  will   require  pharmacologic  therapy  4   4.  Fulroth  R,  Phillips  B,  Durand  DJ.  Perinatal  outcome  of  infants  exposed  to                                                                                                                                                   cocaine  and/or  heroin  in  utero.  Am  J  Dis  Child.  1989;143  :905  –910    
  13. 13. S,mulants  •  Signs  may  include:   –  Tremors   –  High-­‐pitched  cry   –  Irritability   –  Hyper-­‐alertness   –  Apnea   –  Tachycardia  •  Most  commonly  seen  around  72  hours  of  age  
  14. 14. S,mulants  •  Infants  exposed  to  methamphetamine  or  cocaine   also  may  exhibit:  5   –  Higher  rates  of  prematurity   –  IUGR   –  Asphyxia  secondary  to  placental  abrup@on  •  Mul@ple  drug  use  is  common  in  this  group   –  Which  will  oRen  complicate  the  clinical  picture  5.  Eyler  FD,  Behnke  M,  Garvan  CW,  Woods  NS,  Wobie  K,  Conlon  M  .  Newborn  evalua@ons  of  toxicity  and  withdrawal  related  to  prenatal  cocaine  exposure.  Neurotoxicol  Teratol.    2001;23(5):399–411  
  15. 15. Depressants  and  Seda,ves  •  Ethanol  withdrawal  may  be  seen  as  early  as  3  to  12  hours   of  life   –  Physical  findings  of  FAS  may  be  superimposed  •  Classic  signs  of  NAS  (irritability,  poor  feeding,  crying)  may   be  seen   –  Although  the  severity  is  much  less  compared  to  infants  exposed   to  opioids  
  16. 16. SSRI’s  •  Selec@ve  Serotonin   •  Poten@al  effects  seen  in   Reuptake  Inhibitors:   infants  exposed  are:  7   –  Most  commonly   –  Con@nuous  crying   prescribed  medica@on   –  Irritability   for  depression  6   –  Fever   –  Tachypnea   –  Tremors   –  Hypoglycemia   –  Seizures  6.  Alwan  S,  Friedman  JM  .  Safety  of  selec@ve  serotonin  reuptake  inhibitors  in  pregnancy.  CNS  Drugs.  2009;23(6):493–509  7.  Haddad  PM,  Pal  BR,  Clarke  P,  Wieck  A,  Sridhiran  S  .  Neonatal  symptoms  following  maternal  paroxe@ne  treatment:  serotonin  toxicity  or  paroxe@ne  discon@nua@on  syndrome?  J  Psychopharmacol.  2005;19(5):554–557  
  17. 17. SSRI’s  •  Debate  over  source  of  signs  and  symptoms   –  Excess  serotonin  (drug  itself)   –  Low  serotonin  (withdrawal  of  drug)  •  SSRI’s  seem  to  be  safe  in  pregnancy   –  Many  reviews  have  not  shown  long  term   neurodevelopmental  impairment  8   8.  Mark  L.  Hudak,  MD,  Rosemarie  C.  Tan,  MD,  PhD,  THE  COMMITTEE  ON  DRUGS,  and  THE   COMMITTEE  ON  FETUS  AND  NEWBORN.  Neonatal  Drug  Withdrawal.  Pediatrics  Vol.  129  No.  2   February  1,  2012  
  18. 18. Abs,nence  scoring  systems  •  Many  scoring  systems  exist   –  No  par@cular  one  has  been  adopted  as  “the  standard”  •  The  most  comprehensive  and  widely  used  is  the   Finnegan  scoring  system  9  •  The  Finnegan  scoring  system  takes  20  of  the  most   common  signs  and  groups  them  into:   –  CNS  disturbances   –  Metabolic/Vasomotor/Respiratory  disturbances   –  GI  disturbances   9.  Finnegan  LP,  Connaughton  JF  Jr,  Kron  RE,  Emich  JP.  Neonatal  abs@nence  syndrome:   assessment  and  management.  Addict  Dis.  1975;2  :141  –158    
  19. 19. Finnegan  Scores  •  The  signs  were  ranked  according  to  pathologic   significance   –  Those  with  the  least  poten@al  for  adverse  affects  were  given  a   “1”   –  Those  with  the  most  poten@al  for  adverse  affects  were  given  a   “5”   –  A  score  of  7  or  less  is  considered  mild  and  babies  do  well  with   nonpharmacologic  comfort  measures   –  A  score  of  8  or  greater  generally  indicates  that  infants  may  need   pharmacologic  therapy  
  20. 20. Opioid  Withdrawal  Recap  •  Mostly  affects:   –  CNS   –  Autonomic  nervous  system   –  Gastrointes@nal  system  •  Other  things  to  keep  in  mind:   –  Presenta@on  will  vary  depending  upon:   •  Maternal  dose   •  Placental  metabolism   •  Maternal  drug  history   •  Polysubstance  abuse  
  21. 21. Prematurity  •  Some  studies  suggest  a  lower  risk  for   withdrawal  10  •  However,  the  classic  signs  may  not  be  present   –  Scoring  systems  developed  around  Term  infants   –  Decreased  maturity  of  CNS  system   –  Less  adipose  @ssue  •  Good  maternal  history  and  general   assessment  of  infants  status  is  key  10.  Liu  AJ,  Jones  MP,  Murray  H,  Cook  CM,  Nanan  R  .  Perinatal  risk  factors  for  the  neonatal  abs@nence  syndrome  in  infants  born  to  women  on  methadone  maintenance  therapy.  Aust  N  Z  J  Obstet  Gynaecol.  2010;50(3):253–258.  
  22. 22. Prenatal  Screening  •  Consider  prenatal  screening  if  certain  risk   factors  present   –  Absent/Late  prenatal  care   –  Unexplained  fetal  demise   –  Placental  abrup@on   –  Large  swings  in  cardiovascular  status   –  Prior  history  of  drug  abuse  •  Can  be  a  delicate  issue  
  23. 23. Is  it  NAS?  •  Be  aware  of  other  systemic  disorders  that  may   have  similar  symptoms   –  Hypoglycemia   –  Inborn  errors  metabolism   –  Calcium  dysregula@on   –  Intracranial  process  (HIE,  hemorrhage)   –  Uncommon  neuromuscular  disorders  
  24. 24. What  to  Expect?   11,12   Heroin   Methadone   Buprenorphine   Onset  of   Usually  by  24   Usually  1-­‐3   Usually    2-­‐3   Symptoms   hours   days   days   •  However,  some  infants  may  not  display  signs   un@l  5-­‐7  days  11.  Zelson  C,  Rubio  E,  Wasserman  E  .  Neonatal  narco@c  addic@on:  10  year  observa@on.  Pediatrics.  1971;48(2):  12.  Kandall  SR,  Gartner  LM  .  Late  presenta@on  of  drug  withdrawal  symptoms  in  newborns.  Am  J  Dis  Child.  1974;127(1):58–61  
  25. 25. Treatment  •  The  treatment  should  begin  with  non-­‐ pharmacologic  measures   –  Gentle  handling   –  Ambient  noise  control   –  Swaddling   –  On  demand  feeding  •  Be  mindful  of  infants  needs   –  Caloric  requirement,  sleep..etc  
  26. 26. Pharmacologic  Treatment  •  Pharmacotherapy  may  be  helpful  if…   –  Seizures  are  present   –  Weight  loss/Dehydra@on   •  Secondary  to  vomi@ng  and  diarrhea   –  Poor  feeding  skills  •  Opioids  (morphine/methadone)     –  Reduce  excessive  bowel  mo@lity   –  Reduc@on  of  seizures  
  27. 27. Pharmacologic  Treatment  •  What  is  a  concerning  score?  (Finnegan)   –  Usually  8  or  higher  •  Goal  of  therapy?   –  Allow  gradual  withdrawal   –  Absence  of  excessive  excita@on  •  The  length  of  the  weaning  process  may  vary  
  28. 28. Morphine  vs.  Methadone  •  Morphine   –  Shorter  half  life  (4-­‐16  hours)   –  Poten@al  to  “capture”  quicker  •  Methadone   –  Longer  half  life  (16-­‐25  hours)   –  Less  frequent  dosing  
  29. 29. Na,onwide  Children’s  Protocol  •  Enteral  morphine  based  •  Ini@ate  protocol  if   –  2  consecu@ve  scores  above  8     –  1  score  above  12   •  Both  within  a  24  hour  period  •  Star@ng  dose   –  Morphine  0.05  mg/kg/dose  PO  q  3  hours   •  IV  would  be  0.02  mg/kg/dose  
  30. 30. NCH  Protocol  Cont.  •  Escala@on   –  Increase  Morphine  by  0.025-­‐0.04  mg/kg/dose  every  3   hours  un@l  scores  <  8   –  If  IV,  increase  by  0.01  mg/kg/dose  •  Rescue  dose   –  If  scores  are  s@ll  above  12   •  Double  the  previous  dose  x  1   •  If  s@ll  above  12,  increase  dose  by  50%   –  Un@l  captured  •  Rescue  dose  only  in  ini@al  phase  
  31. 31. NCH  Protocol  Cont.  •  Stabiliza@on   –  Once  captured  (scores  <8)  con@nue  maintenance  dose   for  72-­‐96  hours  •  Weaning   –  Following  the  above,  wean  by  10%  every  24  to  48   hours   –  Do  not  rou@nely  weight  adjust  meds   –  Drug  may  be  d/c’ed  when  a  single  dose  is                                                   <  0.02  mg/kg/dose  q  3  hours  
  32. 32. NCH  Protocol  Cont.  •  Problems  with  weaning   –  If  scores  following  a  wean  are  above  8   •  Ensure  comfort  measures   –  Maximize  swaddling   –  Holding   –  Decreased  s@muli   –  Go  back  to  dose  where  infant  was  stable   –  Do  not  use  rescue  dose   –  Consider  weaning  at  longer  intervals   •  48  hours  vs  24  hours   –  Monitor  for  48-­‐72  hours  prior  to  d/c  
  33. 33. Adjunct  Therapy  •  Consider  a  second  agent  if:   –  Infant  has  2  consecu@ve  weaning  failures   –  No  progress  in  weaning  off  morphine  by  day  14   –  May  be  added  earlier   •  Based  on  infants  symptoms   •  Maternal  history  
  34. 34. Adjunct  Therapy  •  Phenobarbital   –  Binds  to  GABA  receptors   –  Helps  with  CNS  issues  such  as   •  Irritability,  sleeplessness  and  tone   –  Has  been  shown  to  reduce  LOS,  and  severity  of   withdrawal  13  13.  Coyle  MG,  Ferguson  A,  Lagasse  L,  Oh  W,  Lester  B.  Diluted  @ncture  of  opium  (DTO)  and  phenobarbital  versus  DTO  alone  for  neonatal  opiate  withdrawal  in  term  infants.  J  Pediatr  2002;  140(5):  561–564  
  35. 35. Adjunct  Therapy  •  Phenobarbital  may  be  beneficial  if   –  CNS  symptoms  predominate   •  (Hyperac@ve  reflexes,  tremors,  increased  tone)   –  History  of  polysubstance  abuse  
  36. 36. Adjunct  Therapy  •  Cau@ons  with  phenobarbital   –  Poten@al  to  oversedate     –  Impaired  feeding   –  Drug  interac@ons   –  Longer  half  life  (45-­‐100hr)   –  Alcohol  content  (15%)  
  37. 37. Adjunct  Therapy  •  Clonidine   –  Alpha  2  adrenergic  receptor  agonist   •  Ac@vates  inhibitory  neurons   •  Reduced  sympathe@c  tone   –  Has  been  shown  to  help  with   •  Faster  stabiliza@on   •  Decreased  dosing  requirements  of  opioid  therapy  14   14.  Agthe  AG,  Kim  GR,  Mathias  KB,  Hendrix  CW,  Chavez-­‐Valdez  R,  Jansson  L  et  al.  Clonidine  as   an  adjunct  therapy  to  opioids  for  neonatal  abs@nence  syndrome:  a  randomized,  controlled   trial.  Pediatrics  2009;  123(5):  e849–e856  
  38. 38. Adjunct  Therapy  •  Clonidine     –  May  be  useful  if  majority  of  symptoms  are  in  the   autonomic  category   •  (swea@ng,  fever,  yawning,  mokling..etc)   –  Monitor  for  hypotension  and  bradycardia   –  Avoid  rapid  discon@nua@on   –  Observe  for  48  hours  off  prior  to  d/c   •  Do  not  recommend  treatment  as  outpa@ent  
  39. 39. Prenatal  Counseling  •  Many  mothers  feel  anxiety  and  guilt   –  Clinicians  should  be  prepared  to  be  empathe@c  and   nonjudgmental    •  Essen@al  components  to  prenatal  counseling  include:   –  Poten@al  for  teratogenicity   –  Expected  clinical  course   –  Breasueeding  and  Lacta@on   –  Social  considera@ons  
  40. 40. Social  Considera,ons  •  Be  empathe@c  and  nonjudgmental  •  Be  aware  of  maternal  psychosocial  status   –  Is  there  signs  of  postpartum  depression?   –  Is  counseling  a  reasonable  resource?  •  Always  be  honest   –  Not  every  baby  follows  the  rules   –  Updates  frequently  regarding  status  
  41. 41. The  Innocent  Vic@ms:  Neonatal   Abs@nence  Syndrome   Carla  Saunders,  NNP-­‐BC  
  42. 42. Epidemiology    NIDA  es@mates  $600  billion  is  spent  annually  on  costs  associated  with   substance  abuse  in  U.S.     American  Diabetes  Associa@on  es@mates      annual  costs  associated  with  diabetes  is  $174  billion  in  2007.     Na@onal  Cancer  Ins@tute  es@mates      $125  billion  in  annual  costs  for  cancer  care  in  2010.  •  2009  Na@onal  Survey  on  Drug  Use  and  Health:   •  4.5  percent  of  pregnant  women  aged  15  to  44  have  used  illicit  drugs  in  the  past   month.   •  In  2008  there  were  9430  babies  born  in  Knox  County  according  to  Knox  County  hospitals  birth   records:  Es@mated  424  babies  born  annually  in  Knox  County  whose  mother  used  illicit  drugs  in   the  past  month.  •  2009  Key  Birth  Stats  from  CDC  report  4,131,019  births  in  U.S.   •  Approximately  186,000  babies  born  to  mothers  who  used  illicit  drugs  in  past  month  1.  NIDA  InfoFacts:  Understanding  Drug  Abuse  and  Addic@on.  Na@onal  Ins@tute  on  Drug  Abuse.  hkp://www.drugabuse.gov/infofacts/understand.html.   Accessed  May  28,  2011  2.  Diabetes  Cost  Calculator.  American  Diabetes  Associa@on.  hkp://www.diabetesarchive.net/advocacy-­‐and-­‐legalresources/cost-­‐of-­‐diabetes.jsp.  Accessed  May   28,  2011.  3.  The  Cost  of  Cancer.  Na@onal  Cancer  Ins@tute.  hkp://www.cancer.gov/aboutnci/servingpeople/cancer-­‐sta@s@cs/costofcancer.  Accessed  May  28,  2011.  4.  Substance  Abuse  and  Mental  Health  Services  Administra@on.  (2010).  Results  from  the  2009  NaMonal  Survey  on  Drug  Use  and  Health:  Volume  I.  Summary  of     NaMonal  Findings  (Office  of  Applied  Studies,  NSDUH  Series  H-­‐38A,  HHS  Publica@on  No.  SMA  10-­‐4856Findings).  Rockville,  MD.  5.  Number  of  Babies  Born.  Kids  Count  Data  Center.  hkp://datacenter.kidscount.org/data/bystate/Rankings.aspx?state=TN&ind=2996.  Accessed  May  27,  2011.
  43. 43. 1999  Veterans  Health  Admin.  Ini,a,ve:  “Pain  as  the  5th  Vital  Sign”   JCAHO  ins,tute  pain  standards  in  2001   Cocaine   Heroin  
  44. 44. Neonatal  Abs@nence  Syndrome  (NAS)    Constella@on  of  withdrawal  symptoms     CNS     Inconsolability,  high-­‐pitched  crying,  skin  excoria@on,  hyperac@ve  reflexes,  tremors,   seizures     GI     Poor  feeding,  excessive  sucking,  feeding  intolerance,  loose  or  watery  stools     Autonomic/metabolic     Swea@ng,  nasal  stuffiness,  sneezing,  fever,  tachypnea,  mokling  
  45. 45. Tolerance  –  Dependence  –  Addic@on  •  Tolerance   –  Our  body  develops  tolerance  to  a  drug’s  effect  so  that   an  increased  amount  of  drug  is  required  to  produce   effect.    •  Dependence   –  If  the  supply  of  the  drug  is  removed  then  the  person  will   exhibit  “withdrawal  symptoms”.    •  Addic@on   –  The  con@nuing,  compulsive  nature  of  the  drug  use   despite  physical  and/or  psychological  harm  to  the  user   and  society  
  46. 46. Unique  Concerns  for  the  Substance   Abusing  woman  US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration. SubstanceAbuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.
  47. 47. 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 ofChildrearing Age. Rockville, MD.
  48. 48. Return  on  Investment  •  For  every  $1  spent  on  addic@on  treatment   programs   –  $4  to  $7  saved  in  reduced  drug-­‐related  crime,   criminal  jus@ce,  and  theR   –  Up  to  $12  saved  when  including  health-­‐care  costs   –  Other  considera@ons   •  Neonatal  abs@nence  syndrome  might  be  reduced  NIDA. Principles of Drug Addiction Treatment, A research-based Guide. NIH Publication No. 09-4180. April 2009 •  Greater  workplace  produc@vity  
  49. 49. Incidence  of  Maternal  Opiate  Use  and   NAS  Maternal  Opiate  Use  increased  x  5     NAS  Incidence  tripled   Patrick, S. W. et al. JAMA 2012;307:1934-1940
  50. 50. Why  do  expectant  mothers  use  drugs?   Prior  injury  /  chronic  pain   Medical  need  for  pain  management    Appropriately  managed    Inappropriately  managed   In  a  substance  abuse  treatment  program   Confusion  between  symptoms  of  withdrawal  and   pregnancy.  
  51. 51. Why  do  MDs  con@nue  to  prescribe?  •  ACOG  Guidelines  and  SAMSHA  Guildelines   recommend  to  con@nue  methadone  (possibly   buprenorphine)  •  “Lesser  of  two  evils”   –  Risky  drug-­‐seeking  behaviors   –  Goals  of  quelling  cravings   –  Prevent  mini-­‐withdrawals   –  Ceiling  effect  of  being  in  treatment   •  Methadone,  suboxone,  subutex   –  Reveal  danger  of  I.V.  suboxone  
  52. 52.   “Standard  of  care  for  pregnant  women  with  opioid   dependence:  referral  for  opioid-­‐assisted  therapy  with   methadone…emerging  evidence  suggests  that  buprenorphine  also  should   be  considered.”    Abrupt  d/c  of  opioids  can  result  in  preterm  labor,  fetal   distress,  or  fetal  demise    During  intrapartum/postpartum  period,  special   considera@ons  are  needed…ensure  appropriate  pain   management,  prevent  postpartum  relapse,  prevent  risk   of  overdose,  ensure  adequate  contracep@on.  
  53. 53. Prenatal  Care  is  Vital  •  “Adequate  prenatal  care  oRen  defines  the  difference  between   rou@ne  and  high-­‐risk  pregnancy  and  between  good  and  bad   pregnancy  outcomes.  Timely  ini@a@on  of  prenatal  care  remains   a  problem  na@onwide,  and  it  is  overrepresented  among  women   with  substance  use  disorders.  In  part,  the  threat  of  legal   consequences  for  using  during  pregnancy  and  limited  substance   abuse  treatment  facili@es  (only  14  percent)  that  offer  special   programs  for  pregnant  women  (SAMHSA  2007)  are  key  obstacles   to  care.”  US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration. SubstanceAbuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.
  54. 54. Early  Interven@on  •  Window  of  opportunity   –  “Brief  interven@ons  can  provide  an  opening  to   engage  women  in  a  process  that  may  lead  toward   treatment  and  wellness.”  •  Pregnancy  creates  a  sense  of  urgency  to     –  Enter  treatment   –  Become  abs@nent   –  Eliminate  high-­‐risk  behaviors  US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration. SubstanceAbuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.
  55. 55. NAS  Incidence  in  the  U.S.  Patrick, S. W. et al. JAMA 2012;307:1934-1940
  56. 56. TennCare Office of Healthcare Informatics. Neonatal Abstinence Syndrome among TennCare enrollees. September,2012.
  57. 57. American  Academy  of  Pediatrics  (AAP)  Guidelines    “Reported  rates  of  illicit  drug  use…underes@mate  true  rates…”    55  to  94%  of  neonates  exposed  to  opioids  in  utero  will   develop  withdrawal  signs.    Each  nursery  that  cares  for  infants  with  NAS  should  develop   protocol  for  screening  for  maternal  substance  abuse    Screening  is  best  accomplished  by  using  mul@ple  methods    Maternal  history    Maternal  urine  tes/ng    Tes@ng  of  newborn  urine/meconium    May  consider  umbilical  cord  samples  Hudak ML, Tan RC, The Committee on Drugs and The Committee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012;129:e540e560.
  58. 58. AAP  Guidelines  -­‐  Newborn  Observa@on   Risk  Factors   Recommenda,on  •  No  prenatal  care   •  Observe  in  the  hospital    •  Limited  prenatal  care   for  4  to  7  days  •  History  of  substance  use   •  Early  outpa@ent   or  abuse   followup  •  Any  posi@ve  screen   –  Reinforce  caregiver   educa@on  about  late   during  pregnancy   withdrawal  signs  •  Posi@ve  UDS  on   admission    Hudak  ML,  Tan  RC,  The  Commikee  on  Drugs  and  The  Commikee  on  Fetus  and  Newborn.  Neonatal  Drug  Withdrawal.   Pediatrics.  2012;129:e540e560.  
  59. 59. American  Academy  of  Pediatrics  (AAP)  Guidelines  •  Pharmacologic  interven@ons  include:     –  oral  morphine  solu@on,  or  methadone  as  primary   therapy   –  Increasing  evidence  for  clonidine  as  primary  or   adjunc@ve  therapy   –  Buprenorphine  use  as  primary  or  adjunc@ve  therapy   is  also  increasing   –  Treatment  for  polysubstance  exposure  may  include   opioid,  phenobarbital,    and  clonidine  in   combina@on.  Hudak  ML,  Tan  RC,  The  Commikee  on  Drugs  and  The  Commikee  on  Fetus  and  Newborn.  Neonatal  Drug  Withdrawal.   Pediatrics.  2012;129:e540e560.  
  60. 60. ETCH  Haslam  Neonatal  Intensive  Care  •  Unit   152  beds  /  Level  III  NICU  –  60  beds   –  About  30  %  of  our  NICU  admissions     primarily  for  NAS  treatment   –  135  admissions  for  2011   –  283  admissions  for  2012   •  ProjecMng  315  for  2013   –  Highest  daily  census:  37  in  September,  2012   Average  Daily  Census  for  NAS  babies   1st  Quarter  (JAN-­‐MAR)   4th  Quarter  (OCT-­‐DEC)   2011   8   18   2012   29   27  
  61. 61. Our  rate  of  admissions  is  almost  1  baby   every  day…  
  62. 62. Maternal  Drugs  250  200   Single-­‐ Substance   Exposure:   122   34%  150   Poly-­‐Substance   Exposure:   234   66%  100   50   0  
  63. 63. Previous  Treatment  Plan    Goal:  Stabilize  on  meds  and  discharge  to  wean      Drugs:  Methadone  and  Phenobarbital    No  consistent  approach  to  ini@a@on  of  meds,  dosing,  or   weaning  or  criteria  for  discharge    Avg  LOS:  16  days  to  discharge  on  meds    Confusion  of  staff  and  families  about  treatment  and   expecta@ons  
  64. 64. Discharge  Support  •  Discharged  only  to  DCS  approved  caregivers  •  Discharged  with  weaning  schedule  •  Dedicated  pediatric  follow  up  •  Physiatry  follow  up  •  DCS  services  in  the  home  •  Home  health  nursing  visits  with  social  work  support  
  65. 65. Factors  for  Change  in  Treatment  Plan                  Realiza,on  that  safety  plan  was  failing     Barriers  to  compliance     Caregiver  resistance  (biological/foster)     Caregiver  changes     Drug  diversion     Outpa@ent  management  issues     About  80%  of  discharged  NAS  infants  do  not  keep  follow-­‐up     Pediatrician  refusal  to  manage  weans     Observa@ons  that  babies  were  not  receiving  meds     Issues  with  retail  pharmacy  comfort/availability  of  methadone     Former  NAS  infant,  D/C  on  methadone,  presents  DOA  at  ETCH-­‐ED  
  66. 66. ETCH  Mul@disciplinary  Team    Medical  team  (NNP  lead)     PT/OT  and  Speech    Pharmacy     Child  Life    Staff  nurses     Volunteer  Services    Administra@on     Security    Pa@ent  Care  Coordinator     Nutri@on  Services    Social  Work     PCAs    Lacta@on     Unit  Secretaries    Physiatry     Service  Excellence  
  67. 67. Project  Objec@ves    Develop  a  treatment  plan  to  treat  NAS  that  will:     Iden@fy  neonates  at  risk  for  NAS     Consistently  evaluate  the  presence  and  severity  of  withdrawal  symptoms     Standardize  and  simplify  the  opioid  withdrawal  treatment  plan     Ini@ate  appropriate  non-­‐pharmacological  interven@ons  and   pharmacotherapy  to  control  symptoms     Safely  minimize  length-­‐of-­‐stay:     Wean  the  opioid-­‐dependent  infant  as  quickly  as  possible  while   providing  good  control  of  withdrawal  symptoms     Discharge  infant  weaned  from  NAS  pharmacotherapy     Will  not  require  outpaMent  management  of  methadone  
  68. 68. ETCH  Treatment  Plan  •  Holis@c  mul@disciplinary  approach   –  Non-­‐Pharmacological   •  Environment   •  Diet   •  Cuddlers   –  Pharmacological   •  Oral  Morphine  Sulfate   –  Symptom-­‐based  vs  weight-­‐based  dosing   •  Non-­‐narco@c   –  Acetaminophen   –  Simethicone  
  69. 69. Morphine   Algorithm    Literature  review     Goals  for  protocol     Safe     EffecMve     Quick    Iden@fied  treatment  plan     symptom-­‐based  protocol      Dr.  Jansson  /Johns  Hopkins    Adapted  protocol     Simple  to  use     Standardize  treatment   decisions.  
  70. 70. Typical  course  of  treatment  •  70  %  of  NAS  babies   •  30  %  of  NAS  babies   –  Wean  in  20  days   –  Wean  in  60  days   –  No    adjunc@ve  meds   –  Require  adjunc@ve  meds   •  Phenobarbital  (27%)   –  LOS  24  days   •  Phenobarbital  +Clonidine   (7%)   –  LOS  68  days   •  (longest  LOS  =  155  days)  
  71. 71. E026094565  300   Start  date:    3/31/12  280   Weaned  :    5/7/12   Total  ,me:    37  days  260   LOS:    40  days  240   Maternal  Substances:   buprenorphine  220  200   Comorbidi,es:  180  160  140  120  100   80   60   40   20   0  
  72. 72. E025353038  50   Start  date:    10/19/11   Weaned  :  11/21/11  45   Total  ,me:    33  days   LOS:    36  days  40   Maternal  Substances:   opiates,  benzodiazepines  35   Comorbidi,es:  30  25  20  15  10   5   0  
  73. 73. Dysphoric  Phase   Weeks  to  months   Sense  of     Excessive  pain   Anguish,  agi@a@on   Disquiet,  anxiety   Restlessness   malaise   Acute  Phase   Days  to  weeks   Withdrawal  symptoms   Flu-­‐like  symptoms,  nausea  Vomi@ng,  stomach  cramping   Muscle  pain,  spasm   Fever,  swea@ng,     Runny  nose  and  eyes   Insomnia,  anxiety  
  74. 74. E025282872  480  460  440  420  400  380  360   Dysphoric  340  320  300   Phase  280   Polysubstance  260  240  220  200   Start  date:    10/4/11  180  160  140   Acute     Weaned  :    1/19/12   Total  ,me:    107  days   LOS:    134  days  120  100   80   Phase   Maternal  Substances:   methadone,  oxycodone,     benzodiazepines   60   Comorbidi,es:   40   20   0  
  75. 75. Unique  Challenges    Environment            Work  load     Nursing     Pharmacy     Social  Work     Rehabilita@on  Services     Volunteer  Services     Security  
  76. 76. Emo@onal  Challenges  •  A_tudes  /  PercepMons   •  Family  /  Caregiver  Issues   •  Preventable  nature  of   •  Personal  addic@on  of   condi@on   parents   •  Personal  prejudices   •  Mental  health  issues   •  Literacy  problems    •  Feelings   •  Comprehension/ •  Confusion  /  fear   reten@on  issues   –  HIPPA  concerns   –  Ethical  Issues   •  FaMgue/exhausMon/burnout   Educa/onal  deficit  regarding  the  science  of  addic/on  
  77. 77. Public  Health  Issues    NICU  beds  taken  by  infants  whose  only  need  is   withdrawal  treatment    Behavioral  issues  in  childhood     Schools  –  teacher  retraining    Poten@al  long-­‐term  public  health  issue     Genera@onal  addic@on  problems       2nd  and  3rd  genera@onal  behaviors  sustained     Gene@c  predisposi@on?       Does  intrauterine  exposure  ac@vate  gene  in  utero?     Does  NAS  treatment  complicate  addic@ve  tendencies?  
  78. 78. Long-­‐Term  Consequences  of  NAS  •  At  risk  for:   –  Aken@@on  deficit  disorder   –  Hyperac@vity   –  Difficulty  transi@oning  between  tasks   –  Impulse-­‐control   –  Sleep  disorders   –  Sensory  disorders   –  Future  risk  of  addic@ve  behavior  
  79. 79. Lessons  Learned  •  Withdrawal  outpa@ent  is  unreliable  even  unsafe  •  Withdrawal  is  not  linear  •  Consistency  is  invaluable  •  Data  drives  success  •  Challenges  are  unique  to  this  pa@ent  popula@on  •  Scoring  tools  are  not  designed  for  older  neonate  •  Early  capture  may  lead  to  decreased  LOS  
  80. 80. More  lessons….  •  Not  all  drug  “screens”  are  created  equal  •  Collect  meconium  from  first  stool  to  transi@on  •  Maternal  histories  are  not  always  reliable  •  Mother  can  be  posi@ve  and  baby  nega@ve  •  Addic@on  knows  no  boundaries  •  If  it  “quacks”….  You  will  likely  discover  it  IS  a   duck!  
  81. 81. Summary  •  The  impact  of  NAS  does  not  end  in  the  NICU.  •  Long-­‐term  benefits  to  both  the  healthcare  system  and  society   are  significant.  •  Prenatal  care  in  the  otherwise  healthy  woman  is  widely   accepted  to  be  beneficial  to  mothers  and  babies.  •  We  must  do  all  we  can  to  promote  prenatal  care  and   substance  abuse  treatment/counseling  in  this  high-­‐risk   popula@on.  •  Incen@ves  to  seek  help  may  allow  more  opportuni@es  for  the   woman  to  receive  successful  treatment  with  lifelong  benefits.  
  82. 82. Shoot for the moon,even if you miss you’ll land among the stars.

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