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

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. 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. 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. 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.
Harrison's
Principles
of
Internal
Medicine.
17th
edn,
McGraw-­‐Hill:
New
York,
2008

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. 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. 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. 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. 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. 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. 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. 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. S,mulants
• Signs
may
include:
– Tremors
– High-­‐pitched
cry
– Irritability
– Hyper-­‐alertness
– Apnea
– Tachycardia
• Most
commonly
seen
around
72
hours
of
age

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. 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. 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. 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. 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. 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

21. 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

22. 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.

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Adjunct
Therapy
• Phenobarbital
may
be
beneficial
if
– CNS
symptoms
predominate
• (Hyperac@ve
reflexes,
tremors,
increased
tone)
– History
of
polysubstance
abuse

37. Adjunct
Therapy
• Cau@ons
with
phenobarbital
– Poten@al
to
oversedate
– Impaired
feeding
– Drug
interac@ons
– Longer
half
life
(45-­‐100hr)
– Alcohol
content
(15%)

38. 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

39. 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

40. 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

41. 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

42. The
Innocent
Vic@ms:
Neonatal
Abs@nence
Syndrome
Carla
Saunders,
NNP-­‐BC

43. 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.

44. 1999
Veterans
Health
Admin.
Ini,a,ve:
“Pain
as
the
5th
Vital
Sign”
JCAHO
ins,tute
pain
standards
in
2001
Cocaine
Heroin

45. 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

46. 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

47. Unique
Concerns
for
the
Substance
Abusing
woman
US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration. Substance
Abuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.

48. 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.

49. 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

50. 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

51. 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.

52. 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

53.  “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.

54. 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. Substance
Abuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.

56. 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. Substance
Abuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.

57. NAS
Incidence
in
the
U.S.
Patrick, S. W. et al. JAMA 2012;307:1934-1940

58. TennCare Office of Healthcare Informatics. Neonatal Abstinence Syndrome among TennCare enrollees. September,
2012.

59. 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.

60. 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.

61. 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.

62. 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

63. Our
rate
of
admissions
is
almost
1
baby
every
day…

64. Maternal
Drugs
250
200
Single-­‐
Substance
Exposure:
122
34%
150
Poly-­‐Substance
Exposure:
234
66%
100
50
0

65. 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

66. 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

67. 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

68. 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

69. 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

70. 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

71. 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.

72. 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)

73. 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

74. 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

75. 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

76. 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

77. Unique
Challenges
 Environment
 Work
load
 Nursing
 Pharmacy
 Social
Work
 Rehabilita@on
Services
 Volunteer
Services
 Security

78. 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

79. 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?

80. 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

81. 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

82. 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!

83. 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.

84. Shoot for the moon,
even if you miss
you’ll land among the
stars.