disclosure statement · abortion, growth restriction, placenta previa, abruption 24 to 48 hours...
TRANSCRIPT
Disclosure Statement
I have no relevant financial relationships to disclose or
conflicts of interest to resolve
I will discuss unapproved or off-label use of a drug
I will not discuss experimental or investigational use of a
product, drug or device
Between the Devil and the
Deep Blue Sea:
The Challenges of Neonatal
Abstinence Syndrome
Barbara Snapp, DNP, NNP-BC
Neonatal Abstinence Syndrome
Cluster of newborn symptoms
Neonatal Abstinence Syndrome
Cluster of newborn symptoms
surrounded by social stigma
Neonatal Abstinence Syndrome
Cluster of newborn symptoms
surrounded by social stigma
and parental angst
About women
and the substances
they take
NarcoticsHeroin
Morphine
Codeine
Oxycodone
Hydrocodone
Opium
Methadone
Buprenorphine
Fentanyl
Definition of NAS
“Neonatal abstinence syndrome (NAS) is
a group of problems that occur in a
newborn who was exposed to addictive
opiate drugs while in the mother’s womb.”
https://www.nlm.nih.gov/medlineplus/ency/article/007313.htm
Extent of Problem
2000-2009
2 per 1000 births to 6 per 1000 births
Patrick, S. W., Schumacher, R. E., Bennyworth, B. D., Krans, E. E., McAllister, J. M., & Davis, M. M. (2012,
May 9). Neonatal abstinence syndrome and associated health care expenditures United States, 2000-2009.
Journal of the American Medical Association, 307(18), 1934-1940. http://dx.doi.org/10.1001/jama.012.3951
Extent of Problem
2009-2012
7 per 1000 births to 27 per 1000 births
Veeral N. Tolia, M.D., Stephen W. Patrick, M.D., M.P.H., Monica M. Bennett, Ph.D., Karna Murthy, M.D.,
John Sousa, B.S., P. Brian Smith, M.D., M.P.H., M.H.S., Reese H. Clark, M.D., and Alan R. Spitzer, M.D.
N Engl J Med 2015; 372:2118-2126. May 28, 2015. DOI: 10.1056/NEJMsa1500439
55
55
5
Extent of Problem
Average delivery service:
2000 60 NAS infants
Extent of Problem
Average delivery service:
2000 60 NAS infants
5000 150 NAS infants
Extent of Problem
Average delivery service:
2000 60 NAS infants
5000 150 NAS infants
Average LOS: 15-21 days
Extent of Problem
Average delivery service:
2000 60 NAS infants
5000 150 NAS infants
Average LOS: 15-21 days
Average Costs: $4-9,500,000
$1.5 billion dollars
$1.5 billion dollars
81% paid by
Medicaid
http://www.salon.com/2014/04/30/tennessee_just_became_the_first_state_that_will_jail_women_for_their_pre
gnancy_outcomes/
Gov . Bill Haslam signs SB 1391
making Tennessee the first state to
jail women for their pregnancy
outcomes
Katie Mcdonough April 30, 2014
http://www.theatlantic.com/health/archive/2015/05/into-the-body-of-another/392522/
History of Women and Opiates
History of Women and Opiates
Early 1800’s:
Sigmund Freud
published “The
Interpretation of
Dreams” describing
cocaine use for
female “hysteria”
http://www.pbs.org/wgbh/aso/databank/entries/dh00fr.html
History of Women and Opiates
Mid 1800’s:
2/3 of prescriptions for
opioids were for
women
History of Women and Opiates
“Fussy” newborns given:
Morphine
Paregoric
History of Women and Opiates
History of Women and Opiates
Harrison Narcotic
Tax Act 1914
“bring the domestic
traffic in narcotics into
the open under a
licensing system, so that
the sloppy dispensing
practices of the day
could be checked”
King, R. B. (1953, April). The narcotics bureau and the Harrison Act: Jailing
the healers and the sick. The Yale Law Journal, 62(5), 784-787
History of Women and Opiates
Harrison Narcotic Tax
Act 1914
Curb recreational
drug use by limiting
prescribing of
narcotics to
physicians within a
physician-patient
relationship
History of Women and Opiates
Addiction was unrecognized and
women were suddenly left adrift
History of Women and Opiates
Beginning
of criminal
journey of
narcotic addiction
When Addiction Became a Problem
1971
Congressmen
Robert Steele (CT)
and Morgan
Murphy (IL)
traveled to Vietnam
When Addiction Became a Problem
1971
When Addiction Became a Problem
15%
soldiers
were
addicted to
heroin
Methadone Becomes
Treatment for Addiction
Methadone
• Created 1930’s in Germany
Methadone
• Created 1930’s in Germany
• 1960’s:
NY Physicians studying metabolic disorders
-Obesity and addictive behavior
Methadone
• Created 1930’s in Germany
• 1960’s:
NY Physicians studying metabolic disorders
-Obesity and addictive behavior
-Enrolled heroin addicts
Methadone
• Created 1930’s in Germany
• 1960’s:
NY Physicians studying metabolic disorders
-Obesity and addictive behavior
-Enrolled heroin addicts
studied on morphine
Methadone
• Created 1930’s in Germany
• 1960’s:
NY Physicians studying metabolic disorders
-Obesity and addictive behavior
-Enrolled heroin addicts
studied on morphine
weaned using methadone
Methadone
Morphine Methadone
Watching
television
Went back to
school
Methadone
Morphine Methadone
Watching
television
Went back to
school
Facing prison Living
independently
Methadone
Morphine Methadone
Watching
television
Went back to
school
Facing prison Living
independently
Costing society Contributing to
society
Methadone
Morphine Methadone
Watching
television
Went back to
school
Facing prison Living
independently
Costing society Contributing to
society
Methadone influenced quality of life behaviors
Until 1990’s
addiction treatment
focused on men
1995
2001
best
selling
narcotic
pain
reliever
http://www.drphil.com/articles/article/225
http://prohttp://programs.ccm-ct.org/Plugs/discount-prescription-cards.aspx
2014: 200 MILLION opiate
prescriptions written
Prescription Drug Monitoring
Programs
37 states have PDMP
11 are planning PDMP
CDC Guideline for Prescribing Opioids for Chronic
Pain — United States, 2016
Recommendations and Reports / March 18, 2016
/ 65(1);1–49
Why is substance use
such a problem?
Photo by Katie Nesling/Thinkstock
Brain
• endogenous opiate-like substances
Brain
• endogenous opiate-like substances
• enkephalins, endorphins, endomorphins,
and dynorphins
Brain
• endogenous opiate-like substances
• enkephalins, endorphins, endomorphins,
and dynorphins
• neuropeptides used as neurotransmitters
send chemical messages
throughout body
http://www.faim.org/neurotransmitters-and-the-brain-denver-colorado
Chemical
messengers
Brain
Neurotransmitters associated with pain
perception bind with opioid receptors:
mu (μ), delta (δ), kappa (κ)
Brain
Reduces perception of pain
by inhibiting firing of nerve cells
Brain
Limbic system
is loaded with
opiate receptors
https://en.wikipedia.org/wiki/Mesolimbic_pathway#/media/File:Mesolimbic_pathway.svg
Brain
Limbic system associated with:
• Emotions: fear, anxiety, pleasure, anger
Brain
Limbic system associated with:
• emotions: fear, anxiety, pleasure, anger
• drives: sex, food, maternal behaviors
Brain
VTA
https://en.wikipedia.org/wiki/Mesolimbic_pathway#/media/File:Mesolimbic_pathway.svg
Mesolimbic
dopamine
pathway
originates
in ventral
tegmental
area (VTA)
Opiates in the Brain
Connects to
nucleus
accumbens:
Area associated
with motivation
and reward
http://imgur.com/gallery/IpXaQBc
Dopamine is
neurotransmitter
“love molecule”
Associated with:
Lust
Attention-seeking behavior
Motivation
Addiction
http://www.livescience.com/18079-women-feel-pain-intensely-men.html
We don’t produce enough endogenous
opiates for severe pain
Brain
Exogenous opiates (heroin, morphine) • react with same receptors (mu, delta, kappa)
• reduces excitability of neurons
• produces feelings of euphoria
• inhibits neurons that control breathing
• slows signals in the digestive tract
• “dulling” of neurons requires drug increase
Brain
Opiates block GABA
(Gamma Amino Butyric Acid)
Brain
Gamma Amino Butyric Acid (GABA)
• acts as a neurotransmitter
• inhibits nerve transmission
• reduces nerve excitability
• limits dopamine release
https://www.cnsforum.com
https://www.cnsforum.com
http://allisonfriese.com/tag/dopamine/
Lust
Attention-seeking
behavior
MotivationAddiction
Opioids in the Brain
• Drowsiness
• Mental confusion
• Nausea
• Constipation
• Depress respiration
• Euphoria
https://www.drugabuse.gov
Definitions
Definitions
• Addiction
• Dependence
• Abuse
Addiction
• Neuronal adaptation in the brain to the chemical influence of certain drugs
Addiction
• Neuronal adaptation in the brain to the chemical influence of certain drugs
• Changes brain composition and operation
Addiction
• Neuronal adaptation in the brain to the chemical influence of certain drugs
• Changes brain composition and operation
• Addict has cravings and inability to properly manage their drug use
Addiction
• Neuronal adaptation in the brain to the chemical influence of certain drugs
• Changes brain composition and operation
• Addict has cravings and inability to properly manage their drug use
• Will continue despite grave personal consequences
Dependence
• Similar to addiction except the user requires increasing amounts of their drug
Dependence
• Similar to addiction except the user requires increasing amounts of their drug
• Recognition of the desire to stop using or the preoccupation with quitting
Dependence
• Similar to addiction except the user requires increasing amounts of their drug
• Recognition of the desire to stop using or the preoccupation with quitting
• Continue to use large quantities of their drug despite damaging outcomes or results
Abuse
Ongoing use of a drug despite what can be
catastrophic consequences
Abuse
Ongoing use of a drug despite what can be
catastrophic consequences
• Legal
Abuse
Ongoing use of a drug despite what can be
catastrophic consequences
• Legal
• Social
Abuse
Ongoing use of a drug despite what can be
catastrophic consequences
• Legal
• Social
• Risk to their own safety
http://www.nigerianweddingsguide.com/signs-of-an-abusive-relationship.html
Drug use associated
with:
http://www.nigerianweddingsguide.com/signs-of-an-abusive-relationship.html
Drug use associated
with:
•Intimate partner abuse
http://www.nigerianweddingsguide.com/signs-of-an-abusive-relationship.html
Drug use associated
with:
•Intimate partner abuse
•Sexual assault
http://www.nigerianweddingsguide.com/signs-of-an-abusive-relationship.html
Drug use associated
with:
•Intimate partner abuse
•Sexual assault
•Physical violence
http://www.nigerianweddingsguide.com/signs-of-an-abusive-relationship.html
Drug use associated
with:
•Intimate partner abuse
•Sexual assault
•Physical violence
•Dysfunctional families
http://www.nigerianweddingsguide.com/signs-of-an-abusive-relationship.html
Drug use associated
with:
•Intimate partner abuse
•Sexual assault
•Physical violence
•Dysfunctional families
•Dangerous environment
http://www.nigerianweddingsguide.com/signs-of-an-abusive-relationship.html
Drug use associated
with:
•Intimate partner abuse
•Sexual assault
•Physical violence
•Dysfunctional families
•Dangerous environment
•Unstable relationships
Mental health
issues:
http://cambridgecitizen.ca/correctional-services-women-and-mental-health/
Mental health
issues:
• Depression
http://cambridgecitizen.ca/correctional-services-women-and-mental-health/
Mental health
issues:
• Depression
• Anxiety
http://cambridgecitizen.ca/correctional-services-women-and-mental-health/
Mental health
issues:
• Depression
• Anxiety
• Eating disorders
http://cambridgecitizen.ca/correctional-services-women-and-mental-health/
Mental health
issues:
• Depression
• Anxiety
• Eating disorders
• Emotional abuse
http://cambridgecitizen.ca/correctional-services-women-and-mental-health/
Mental health
issues:
• Depression
• Anxiety
• Eating disorders
• Emotional abuse
• Unstable housing
http://cambridgecitizen.ca/correctional-services-women-and-mental-health/
Affects all
income levels
NEUROBEHAVIORAL DISORDER
http://pubs.niaaa.nih.gov/publications/arh312/111-118.pdf
Alcohol
dependence
Drug
dependence
Conduct
disorder
Antisocial
personality
disorder
Disorder
-specific
genes
Genes influencing
externalizing
psychopathy
Disorder
-specific
geneshttp://pubs.niaaa.nih.gov/publications/arh312/111-118.pdf
Women and Substance Use
• Women are more susceptible to
opiates
Women and Substance Use
• Women are more susceptible to
opiates
• Go more quickly from use to abuse
Women and Substance Use
• Women are more susceptible to
opiates
• Go more quickly from use to abuse
• More women suffer from multiple
influences
Words Not to Use
Words Not to Use
• Addict
Words Not to Use
• Addict
• Abuser
Words Not to Use
• Addict
• Abuser
• Substance abuser
Words Not to Use
• Addict
• Abuser
• Substance abuser
• Chronic pain med abuser
Words Appropriate to Use
Words Appropriate to Use
• Substance use disorder
Words Appropriate to Use
• Substance use disorder
• Addictive disorder
Words Appropriate to Use
• Substance use disorder
• Addictive disorder
• Addictive disease
Words Appropriate to Use
• Substance use disorder
• Addictive disorder
• Addictive disease
• Chemical dependency
Chemical Dependency
and Pregnancy
Commonly Used Substances
• Opiates
• Cocaine
• Methamphetamines
• Selective Serotonin Reuptake Inhibitors (SSRI’s)
(Zoloft, Paxil, Prozac)• Benzodiazepines
(Ativan, Valium, Xanax)
• Nicotine
• Alcohol
• Marijuana
Drug Prenatal Effects Withdrawal Time Postnatal Effects
Cocaine Growth restriction,
prematurity,
abruption
48-72 hours Mild behavioral
changes
Methamphetamines Abruption,
prematurity, growth
restriction, heart and
brain malformations
48-60+ Neuro-
developmental
changes
SSRI’s No documented
effects
Hours to days Initial hypotonia,
weakness, feeble cry
then hypertonia,
irritability
Benzodiazepine Prematurity, low birth
weight
Variable Mild withdrawal
symptoms
Nicotine Displaces fetal
oxygen,
spontaneous
abortion, growth
restriction, placenta
previa, abruption
24 to 48 hours Irritability, high
pitched cry,
jitteriness, overall
fussiness, poor
feeding, low
threshold for stress
Marijuana Brain development Not evident in
prenatal period
High pitched cry,
jitteriness, poor
sleep patterns
Drug Prenatal Effects Withdrawal Time Postnatal Effects
Cocaine Growth restriction,
prematurity,
abruption
48-72 hours Mild behavioral
changes
Methamphetamines Abruption,
prematurity, growth
restriction, heart and
brain malformations
48-60+ hours Neuro-
developmental
changes
SSRI’s No documented
effects
Hours to days Initial hypotonia,
weakness, feeble cry
then hypertonia,
irritability
Benzodiazepine Prematurity, low birth
weight
Variable Mild withdrawal
symptoms
Nicotine Displaces fetal
oxygen,
spontaneous
abortion, growth
restriction, placenta
previa, abruption
24 to 48 hours Irritability, high
pitched cry,
jitteriness, overall
fussiness, poor
feeding, low
threshold for stress
Marijuana Brain development Not evident in
prenatal period
High pitched cry,
jitteriness, poor
sleep patterns
Drug Prenatal Effects Withdrawal Time Postnatal Effects
Cocaine Growth restriction,
prematurity,
abruption
48-72 hours Mild behavioral
changes
Methamphetamines Abruption,
prematurity, growth
restriction, heart and
brain malformations
48-60+ hours Neuro-
developmental
changes
SSRI’s No documented
effects
Hours to days Initial hypotonia,
weakness, feeble cry
then hypertonia,
irritability
Benzodiazepine Prematurity, low birth
weight
Variable Mild withdrawal
symptoms
Nicotine Displaces fetal
oxygen,
spontaneous
abortion, growth
restriction, placenta
previa, abruption
24 to 48 hours Irritability, high
pitched cry,
jitteriness, overall
fussiness, poor
feeding, low
threshold for stress
Marijuana Brain development Not evident in
prenatal period
High pitched cry,
jitteriness, poor
sleep patterns
Drug Prenatal Effects Withdrawal Time Postnatal Effects
Cocaine Growth restriction,
prematurity,
abruption
48-72 hours Mild behavioral
changes
Methamphetamines Abruption,
prematurity, growth
restriction, heart and
brain malformations
48-60+ hours Neuro-
developmental
changes
SSRI’s No documented
effects
Hours to days Initial hypotonia,
weakness, feeble cry
then hypertonia,
irritability
Benzodiazepine Prematurity, low birth
weight
Variable Mild withdrawal
symptoms
Nicotine Displaces fetal
oxygen,
spontaneous
abortion, growth
restriction, placenta
previa, abruption
24 to 48 hours Irritability, high
pitched cry,
jitteriness, overall
fussiness, poor
feeding, low
threshold for stress
Marijuana Brain development Not evident in
prenatal period
High pitched cry,
jitteriness, poor
sleep patterns
Drug Prenatal Effects Withdrawal Time Postnatal Effects
Cocaine Growth restriction,
prematurity,
abruption
48-72 hours Mild behavioral
changes
Methamphetamines Abruption,
prematurity, growth
restriction, heart and
brain malformations
48-60+ hours Neuro-
developmental
changes
SSRI’s No documented
effects
Hours to days Initial hypotonia,
weakness, feeble cry
then hypertonia,
irritability
Benzodiazepine Prematurity, low birth
weight
Variable Mild withdrawal
symptoms
Nicotine Displaces fetal
oxygen,
spontaneous
abortion, growth
restriction, placenta
previa, abruption
24 to 48 hours Irritability, high
pitched cry,
jitteriness, overall
fussiness, poor
feeding, low
threshold for stress
Marijuana Brain development Not evident in
prenatal period
High pitched cry,
jitteriness, poor
sleep patterns
Drug Prenatal Effects Withdrawal Time Postnatal Effects
Cocaine Growth restriction,
prematurity,
abruption
48-72 hours Mild behavioral
changes
Methamphetamines Abruption,
prematurity, growth
restriction, heart and
brain malformations
48-60+ hours Neuro-
developmental
changes
SSRI’s No documented
effects
Hours to days Initial hypotonia,
weakness, feeble cry
then hypertonia,
irritability
Benzodiazepine Prematurity, low birth
weight
Variable Mild withdrawal
symptoms
Nicotine Displaces fetal
oxygen,
spontaneous
abortion, growth
restriction, placenta
previa, abruption
24 to 48 hours Irritability, high
pitched cry,
jitteriness, overall
fussiness, poor
feeding, low
threshold for stress
Marijuana Brain development No timeframe in
postnatal period
High pitched cry,
jitteriness, poor
sleep patterns
Opiates
Opiates
Morphine, codeine, oxycodone,
hydrocodone, heroin, opium, methadone,
buprenorphine, fentanyl
Abrupt cessation of
opiate use during
pregnancy is
detrimental to fetus
Treat pregnant women
using opiates
Women and Opiates
Treatment:
• methadone (Schedule II)
Women and Opiates
Treatment:
• methadone (Schedule II)
• buprenorphine (Schedule III)
Subutex
Suboxone:
(buprenorphine + noloxone)
Women and Opiates
Methadone:
• Decreases cravings
Women and Opiates
Methadone:
• Decreases cravings
• Delays withdrawal
Women and Opiates
Methadone:
• Decreases cravings
• Delays withdrawal
• Promotes healthy behaviors
Women and Opiates
Methadone:
• Decreases cravings
• Delays withdrawal
• Promotes healthy behaviors
• Improves overall quality of life
Women and Opiates
Buprenorphines:
• Binds with opiate receptors
Women and Opiates
Buprenorphines:
• Binds with opiate receptors
• Mimics opiates but to lesser degree
Women and Opiates
Buprenorphines:
• Binds with opiate receptors
• Mimics opiates but to lesser degree
• Less respiratory suppression
Women and Opiates
Buprenorphines:
• Binds with opiate receptors
• Mimics opiates but to lesser degree
• Less respiratory suppression
• Alleviates withdrawal symptoms
Women and Opiates
Buprenorphines + noloxone
decreases risk of IV use
treats the withdrawal without the “high”
Screening for Substance Use
No ID, no liquor - and
wrinkles don't count
http://www.timesfreepress.com/news/local/story/2014/jul/29/no-id-no-liquor-and-wrinkles-dont-count-universal
Screening Mothers
Universal toxicology screening of all
pregnant women
http://www.naofficesolutions.com/setting-gold-standard/
Toxicology Screening
Maternal urine drug screen (UDS):
• Amphetamines, cocaine, opiates
activity within 2 to 3 days
Toxicology Screening
Maternal urine drug screen (UDS):
• Amphetamines, cocaine, opiates
activity within 2 to 3 days
• Marijuana
activity with several weeks
Screening Mothers
Universal screening
1st prenatal visit
Screening Mothers
Universal screening
1st prenatal visit
-diabetes
Screening Mothers
Universal screening
1st prenatal visit
-diabetes
-hypertension
Screening Mothers
Universal screening
1st prenatal visit
-diabetes
-hypertension
-neurobehavioral disorders
Screening Mothers
Mothers identified with neurobehavioral
issues can be referred to appropriate
community services
Screening Mothers
Hospital admission lacking universal
screening:
Maternal history may help screen for
neurobehavioral disorders
Screening Mothers
Maternal history:
• Late or no PNC
Screening Mothers
Maternal history:
• Late or no PNC
• Admitted drug use
Screening Mothers
Maternal history:
• Late or no PNC
• Admitted drug use
• Partner violence
Screening Mothers
Maternal history:
• Late or no PNC
• Admitted drug use
• Partner violence
• Poor quality environment
Screening Mothers
Obstetrical history:
• Repeated spontaneous abortions
Screening Mothers
Obstetrical history:
• Repeated spontaneous abortions
• Placental abruptions
Screening Mothers
Obstetrical history:
• Repeated spontaneous abortions
• Placental abruptions
• Precipitous delivery
Screening Mothers
Obstetrical history:
• Repeated spontaneous abortions
• Placental abruptions
• Precipitous delivery
• Myocardial infarction
Screening Mothers
Obstetrical history:
• Repeated spontaneous abortions
• Placental abruptions
• Precipitous delivery
• Myocardial infarction
• Cerebral vascular accidents (CVA)
Screening Mothers
Significant chronic pain:
• Motor vehicle accident (MVA)
• Surgical procedures
• Arthritis
https://www.psychologytoday.com/blog/neuronarrative/201106/how-we-know-youre-lying
Neonatal Abstinence
Syndrome
NewbornToxicology Screening
Infant urine drug screen (UDS)
Positive Urine Toxicology Screens
•Alcohol (Ethanol) •3 to 10 hours
•Hydromorphone (Dilaudid)•1 to 2 days
•Amphetamine Methamphetamine •1 to 2 days
•Methaqualone (Quaaludd)•2 weeks
•Barbiturates•2 to 6 weeks
•Methadone (Dolophine)•2 to 3 days
•Benzodiazepines•Moderate use: 3 to 5 days•Heavy abuse: 3 to 6 weeks
•Morphine•1 to 2 days
•Cocaine•Direct: 5 hours
•PCP (Phencyclidine)•2 to 8 days
•Codeine•1 to 2 days
•Propoxyphene (Darvon)
•Direct: 6 hours•Metabolites: 6 to 48 hours
•Heroin (detected as Morphine)1 to 2 days
•http://childabusemd.com/laboratory/toxicology.
•Marijuana (THC metabolite)Urine: Use of one joint: 2 days
Newborn Toxicology Screening
Infant urine drug screen (UDS)
Infant meconium drug screen
Newborn Toxicology Screening
Infant urine drug screen (UDS)
Infant meconium drug screen
- formed in very early 2nd trimester
Newborn Toxicology Screening
Infant urine drug screen (UDS)
Infant meconium drug screen
- formed in very early 2nd trimester
- takes days to collect
Meconium
Newborn Toxicology Screening
Results are presumptive for a positive
UDS or meconium drug screen
until confirmed with further testing
Toxicology Screening
Cord sampling
Positive Urine Toxicology Screens
•Alcohol (Ethanol) •3 to 10 hours
•Hydromorphone (Dilaudid)•1 to 2 days
•Amphetamine Methamphetamine •1 to 2 days
•Methaqualone (Quaaludd)•2 weeks
•Barbiturates•2 to 6 weeks
•Methadone (Dolophine)•2 to 3 days
•Benzodiazepines•Moderate use: 3 to 5 days•Heavy abuse: 3 to 6 weeks
•Morphine•1 to 2 days
•Cocaine•Direct: 5 hours
•PCP (Phencyclidine)•2 to 8 days
•Codeine•1 to 2 days
•Propoxyphene (Darvon)
•Direct: 6 hours•Metabolites: 6 to 48 hours
•Heroin (detected as Morphine)1 to 2 days
•Marijuana (THC metabolite)Urine: Use of one joint: 2 days
$60
Toxicology Screening
Cord sampling
$100+
Toxicology Screening
USDTL
• Always available
http://www.usdtl.com/testing/umbilical-cord-tissue-drug-test-labs
Toxicology Screening
USDTL
• Always available
• 48 hour turn around time
http://www.usdtl.com/testing/umbilical-cord-tissue-drug-test-labs
Toxicology Screening
USDTL
• Always available
• 48 hour turn around time
• Higher sensitivity for detection
http://www.usdtl.com/testing/umbilical-cord-tissue-drug-test-labs
Toxicology Screening
USDTL
• Always available
• 48 hour turn around time
• Higher sensitivity for detection
• Simple collection
http://www.usdtl.com/testing/umbilical-cord-tissue-drug-test-labs
Toxicology Screening
USDTL
• Always available
• 48 hour turn around time
• Higher sensitivity for detection
• Simple collection
• Should be covered by insurance
http://www.usdtl.com/testing/umbilical-cord-tissue-drug-test-labs
Symptoms of NAS
Neurologic
Hypertonicity
Exaggerated Moro
Constant crying
High pitched cry
Grossly altered
sleep state
Sneezing
Excoriated skin
Symptoms of NAS
Neurologic Autonomic
Hypertonicity Tremors
Exaggerated Moro Mottling
Constant crying Nasal stuffiness
High pitched cry Tachypnea
Grossly altered
sleep state
Fever
Sneezing Sweating
Excoriated skin
Symptoms of NAS
Neurologic Autonomic Gastrointestinal
Hypertonicity Tremors Frequent, loose
watery stools
Exaggerated Moro Mottling Frantic sucking
Constant crying Nasal stuffiness Poor feeding skills
High pitched cry Tachypnea Frequent
spitting/vomiting
Grossly altered
sleep state
Fever
Sneezing Sweating
Excoriated skin
Symptoms of NAS
NAS Scoring Tools
NAS Scoring Tools
• Modified Finnegan Neonatal Abstinence
• Lipsitz Neonatal Drug-Withdrawal
• Neonatal Withdrawal Inventory
• Neonatal Narcotic Withdrawal Index
NAS Scoring Tools
• Modified Finnegan Neonatal Abstinence
• Lipsitz Neonatal Drug-Withdrawal
• Neonatal Withdrawal Inventory
• Neonatal Narcotic Withdrawal Index
NAS Scoring Tools
NAS Scoring Tools
Modified Finnegan Lipsitz
High interrater reliability Does not address
interrater reliability
Comes with commercial
educational materials
No commercial materials
available
Screens, monitors and
manages
Screening tool only
(transport decisions)
21 point scale 11 point scale
NAS Scoring Tools
Modified Finnegan Lipsitz
High interrater reliability Does not address
interrater reliability
Comes with commercial
educational materials
No commercial materials
available
Screens, monitors and
manages
Screening tool only
(transport decisions)
21 point scale 11 point scale
NAS Scoring Tools
Modified Finnegan Lipsitz
High interrater reliability Does not address
interrater reliability
Comes with commercial
educational materials
No commercial materials
available
Screens, monitors and
manages
Screening tool only
(transport decisions)
21 point scale 11 point scale
NAS Scoring Tools
Modified Finnegan Lipsitz
High interrater reliability Does not address
interrater reliability
Comes with commercial
educational materials
No commercial materials
available
Screens, monitors and
manages
Screening tool only
(transport decisions)
21 point scale 11 point scale
NAS Scoring Tools
Modified Finnegan Lipsitz
High interrater reliability Does not address
interrater reliability
Comes with commercial
educational materials
No commercial materials
available
Screens, monitors and
manages
Screening tool only
(transport decisions)
21 point scale 11 point scale
Score after a feed every 3 – 4 hours
Observation for NAS
Opiates: 24 to 48 hours
Methadone: 24 to 72 hours
Buprenorphine: 12 to 70 hours
Observation for NAS
Opiates: 24 to 48 hours
Methadone: 24 to 72 hours
Buprenorphine: 12 to 70 hours
Or as long as 5 to 7 days
Observation for NAS
Opiates: 24 to 48 hours
Methadone: 24 to 72 hours
Buprenorphine: 12 to 70 hours
Or as long as 5 to 7 days
If withdrawal is going to occur
majority in 1 week
Observation for NAS
Medication Half Life Time to
Observe
Hydrocodone 4 hours Discharge after 3
days
Methadone 10-60 hours Discharge after 7
days
Observation for NAS
• Depends upon medication, half life of
drug, and infant’s metabolism of drug
Observation for NAS
• Depends upon medication, half life of
drug, and infant’s metabolism of drug
– Heroin withdrawal is earlier and shorter
Observation for NAS
• Depends upon medication, half life of
drug, and infant’s metabolism of drug
– Heroin withdrawal is earlier and shorter
– Buprenorphine is up to 9 months
Observation for NAS
Cofounders may increase length of
observation:
• tobacco
• benzodiazepines
• SSRI’s
• poly drug use
Non-Pharmacologic Care
Non-Pharmacologic Care
• Quiet, calm environment
Non-Pharmacologic Care
Non-Pharmacologic Care
• Soft voices
Non-Pharmacologic Care
• Soft voices
• Slow movement, gentle handling
Non-Pharmacologic Care
• Soft voices
• Slow movement, gentle handling
• Cluster care
Non-Pharmacologic Care
• Soft voices
• Slow movement, gentle handling
• Cluster care
• Tight swaddling
Non-Pharmacologic Care
• Soft voices
• Slow movement, gentle handling
• Cluster care
• Tight swaddling
• Skin to skin holding
Non-Pharmacologic Care
• Dark environment
Non-Pharmacologic Care
• Dark environment
• Non-nutritive sucking
Non-Pharmacologic Care
• Dark environment
• Non-nutritive sucking
• Frequent feeds
Non-Pharmacologic Care
• Dark environment
• Non-nutritive sucking
• Frequent feeds
• Massage therapy, music therapy
Non-Pharmacologic Care
• Dark environment
• Non-nutritive sucking
• Frequent feeds
• Massage therapy, music therapy
• Vertical rocking (not side to side)
Non-Pharmacologic Care
• Dark environment
• Non-nutritive sucking
• Frequent feeds
• Massage therapy, music therapy
• Vertical rocking (not side to side)
• Use of cuddlers
Cuddlers
can be
important
care team
members
The Challenge of Nutrition
Non-Pharmacologic Care
Nutrition:
Breastfeeding is recommended
• mother enrolled in program, monitored
• HIV negative
• not a poly drug or current user
Non-Pharmacologic Care
Nutrition:Breastfeeding and marijuana
• Heavy user, regular medical, occasional user
• Deposited in brain, adipose tissue
• Stored for weeks to months
• Long half life (60 hours)
• Possible infant sedation
• Impaired mother
• ???
BREASTFEEDING MEDICINE Volume 10, Number 3, 2015
Non-Pharmacologic Care
Nutrition:
• Additional nutrition via formula
Non-Pharmacologic Care
Nutrition:
• Additional nutrition via formula
• Hydrolyzed formula
Non-Pharmacologic Care
Nutrition:
• Additional nutrition via formula
• Hydrolyzed formula
• Fortified with additional calories
Non-Pharmacologic Care
Nutrition:
• Additional nutrition via formula
• Hydrolyzed formula
• Fortified with additional calories
• Gavage feeds
Non-Pharmacologic Care
Nutrition:
• Additional nutrition via formula
• Hydrolyzed formula
• Fortified with additional calories
• Gavage feeds
• Small frequent feedings
Non-Pharmacologic Care
Nutrition:
• Additional nutrition via formula
• Hydrolyzed formula
• Fortified with additional calories
• Gavage feeds
• Small frequent feedings
• Monitor weight gain
Pharmacologic Care
Pharmacologic Care
Morphine and Methadone most common
Buprenorphine and clonidine gaining but studies needed
Treat with same classification of drugs
Pharmacologic Care
Adherence to protocol more important
than drug selection
Pharmacologic Care
Standardizing care improves outcomes for infants born with neonatal abstinence
syndrome
April 16, 2016www.sciencedaily.com/releases/2016/04/160416094756.htm>.
NAS Scoring
Pharmacologic treatment initiated
3 consecutive scores >8
or 2 scores >12 within 24 hour period
NAS Scoring
• Score after a feed every 3 to 4 hours
• Wean for average score over 24 hours
NAS Scoring
• Score after a feed every 3 to 4 hours
• Wean for average score over 24 hours
• Medications are given as prescribed
– Methadone q 6 hours
– Morphine q 3-4 hours
Pharmacologic Care
NAS Protocol:
Once captured, weaning takes days to weeks
NAS Scoring
Infants >28 days of age:
awareness of more awake time
Add two to score for weaning
(<11 instead of <8)
NAS Metrics
Medication Treated Treatment
days
LOS
Methadone 11 11-23 14-27
+ Pb 4 28-50 31-53
+Clonidine 1 35 39
Pharmacologic Care
Discharge Planning
Child Protective Services
(CPS)
Virginia Department of
Social Services January
2016
Child and Family Services
Manual C. Child Protective
Services
10.2 Mandated reporting of
substance-exposed infants
Child Protective Services
Reportable conditions:
• Positive toxicology results
Child Protective Services
Reportable conditions:
• Positive toxicology results
• Finding by healthcare provider that infant was
born dependent upon a controlled substance
Child Protective Services
Reportable conditions:
• Positive toxicology results
• Finding by healthcare provider that infant was
born dependent upon a controlled substance
• Child has an illness, disease, or condition which
is attributable to in utero exposure
Child Protective Services
Unless the controlled substance was
prescribed by a physician for the mother
Child Protective Services
Unless the controlled substance was
prescribed by a physician for the mother
Or the mother sought treatment or
counseling
Discharge Planning
• Appropriate referrals in place for mother
Discharge Planning
• Appropriate referrals in place for mother
• Community healthcare follow-up can follow NAS
infant (including weaning medications)
Discharge Planning
• Appropriate referrals in place for mother
• Community healthcare follow-up can follow NAS
infant (including weaning medications)
• Infant is eating and gaining weight
it is not necessary for all symptoms to
disappear
Discharge Planning
• Appropriate referrals in place for mother
• Community healthcare follow-up can follow NAS
infant (including weaning medications)
• Infant is eating and gaining weight
it is not necessary for all symptoms to
disappear
• Caretakers have been taught to score infant
Discharge Planning
• Appropriate referrals in place for mother
• Community healthcare follow-up can follow NAS
infant (including weaning medications)
• Infant is eating and gaining weight
it is not necessary for all symptoms to
disappear
• Caretakers have been taught to score infant
• Caretakers are comfortable with newborn
Quality Improvement Metrics
Education:
Prenatal instruction for Ob/Peri
Staff education
Appropriate family education
Screening:
Adequate maternal screening
Screening of infant as indicated
Initiation of scoring per protocol
Non-pharmocologic interventions:
Family driven care
Comfort strategies
Cuddler program
Medical management:
Initiation of medications per protocol
Weaning per protocol
Discharge Planning:
Multidisciplinary preparation
Appropriate follow-up
Supportive discharge education
Follow up appointments made
Team approach to care
Discharge plan in place
Timely use of medications
Strict adherence to
protocol
Family supported to care for infant
Comfort strategies successful
Reduced nursing care required
Mothers/infants appropriately screened
Scoring initiated in timely manner
Family education initiated prenatally
Mother’s aware of NAS plan of care
and importance of participation
Reduce pharmocologic
intervention
Reduce length of stay
Decrease hospital costs
Improve parent/infant
relationship
Supportive discharge plan of
care
Safe discharge of family
NAS Key Driver Diagram
Aims Primary Drivers Process/Interventions
Thank you for your time and interest
• http://www.nbcnews.com/video/disturbing-video-shows-baby-undergoing-withdrawal-581562435940