effect of substance abuse on the mother and the newborn: experience of wvu healthcare collaboration...

Effect of substance abuse on the mother and the newborn: Experience of WVU Healthcare

Collaboration on Substance Abuse in Pregnancy.

Panitan (Pete) Yossuck M.D. Associate Professor SOM. Pediatrics: Neonatology.Patrick Marshalek M.D. Assistant Professor SOM. Behavioral Medicine & Psychiatry.

Laura Lander MSW, LICSW. Assistant Professor SOM. Behavioral Medicine & Psychiatry.Courtney Sweet PharmD, BCPS. Pharmacy Clinical Specialist, Pharmaceutical Services WVUH

Disclosure.

• Nothing to disclose.

• All drugs (in neonate) discussed are off label.

Objectives• To be aware of the WVU Healthcare Collaboration for Substance

Abuse in Pregnancy.

• To understand the current situation of substance abuse in pregnancy; prevalence, societal cost, drugs of abuse and treatment.

• To be familiar with substance abuse and addiction program at WVU Healthcare at Chestnut Ridge Center.

• To understand the WVUCH Neonatal Abstinence Syndrome (NAS) QI project and describe the postnatal management of newborn infants with NAS.

Effects of Substance Abuse in pregnancy on mother and newborn

Patrick Marshalek, MDLaura Lander, MSW, LICSW

Prevalence• NSDUH 2009-2010 illicit drug use

– Pregnant women age 12-17 – 16.2%– Pregnant women age 18-25 – 7.4%– Pregnant women 26-44 – 1.9%

• Stitely, 2010– 759 samples or chord blood taken– 142 + for drugs or alcohol (19.2%)

• Most common THC and opioids

• Montgomery, 2008– Among patients at high risk for substance abuse, 32% of infant cord tissue

tested positive for drugs • Over 1 million babies are born every year to mothers who abuse substances• 4,000 in WV

• Treatment improves birth outcomes

Delivery/Infant Complications

• Higher incidence of premature labor– Breathing problems– Feeding problems

• Withdrawal– NAS - opioids– Nicotine– Cocaine– Sedative/Hypnotic– Amphetamine

Post Delivery issues

• NAS/NOWS• Breast feeding• Increase risk of relapse• Increased risk of dropping out of treatment• Post partum depression• Pain management• Negative family interactions• Guilt and Shame

The Disease of Addiction

• Biological• Dependence, Tolerance, Withdrawal

• Psychological• Obsession and Compulsion

• Social• Consequences

Drugs of Abuse

• Classification– Opioids, sedatives, stimulants…

• Intoxication/Withdrawal/Tolerance– Use to feel normal

• Routes of Administration– Like in medicine

• Detection– BAL/UDS

Pregnant Women with substance use disorders

• Higher rates of domestic violence• High levels of shame and guilt • Fear CPS intervention • Women with addiction often do not have regular

menses so may not realize they are pregnant right away

• Childcare issues• Transportation issues• Employment issue/financial limitations• At risk for medial complications

Treatment

• Biological– Medication Assisted Treatment (MAT)

• Methadone• Buprenorphine• Naltrexone• Vivitrol

– Detoxification

Medication Assisted Treatment

• Why MAT (Volkow, NEJM, 2014)– Safe– Cost effective– Reduced overdoes rates– Improved retention in treatment– Improved social functioning– Reduced risk of infectious disease transmission– Reduced criminal activity

Treatment

• Psychological– Individual therapy– Group therapy– Approaches

• Supportive• Motivational• Cognitive Behavioral Therapy• Contingency management

Treatment

• Social– 12 Steps

• NA, AA, Al-Anon, others

– Self help meetings for patient and family members• Treatment improves outcomes for whole family

• Abstinence versus Recovery

Levels of Care

• Outpatient (COAT)– MAT

• COAT/OTP

• Intensive Outpatient (AIOP)– Dual diagnosis

• Partial Hospitalization (PHP)• Acute Inpatient

– Detox needs or safety concerns• Residential

Chestnut Ridge Center ModelComprehensive Opioid Addiction Treatment (COAT)

Participants must:

• understand and sign a written contract• attend at least 4 AA or NA meetings per week• Attend group therapy• participate in random drug screens

(occasionally observed)• Patient must actively work the 12 steps

WVUCH NICU: Neonatal Opioid Withdrawal Syndrome (NOWS)

Panitan (Pete) Yossuck. M.D. Section of Neonatology

Pediatrics. School of Medicine

The incidence of infants with history of maternal drug exposure admitted to WVUH NICU was significantly increased in 2011.

(Nanda S. WVU Medical Journal ; in press 2014)

http://www.google.com/url?url=http://givingtuesday.org/partner/wvu-childrens-hospital/&rct=j&frm=1&q=&esrc=s&sa=U&ei=0HiWU7nvMNahyASuxoHoBA&ved=0CEQQ9QEwETgo&usg=AFQjCNEHklVUVpv0XNqS7dWi8gJosmqQfg

The number of infants with history of in-utero buprenorphine exposure increased from 1 case in 2009 (0.18%), 2 cases in 2010 (0.37%) to 25 cases in 2011(4.5%), while the number of infants exposed to maternal methadone showed no drastic changed

(1.5, 1.7 and 2.1% accordingly).



The incidence of infants who developed NAS and required pharmacological therapy decreased significantly in 2011 ; only

one third of infants had NAS that required pharmacological treatment.



Background

• Modified Finnegan NAS scoring system has been used without standardization.

• No specific guidelines for scoring, diagnosis, treatment for NAS.

• Care for infants with NAS was directed discretely based on neonatologist attending on service


Clinical Aims

• Develop the guideline for management of infants with NAS.

• Clinical Parameter after two years of implementation:– Adherence to the guideline– LOS: shorten by 15% while maintain the mean LOS of

untreated infant at 3 days– Reduce outliner by 25%( LOS more than 21 days)– Length of Treatment (LOT)


VONS DATA: Soll R. 2014

Matern

al Scr

eening

Evalu

ation an

d Trea

tmen

t

Standard

ization of s

ource

Non pharmaco

logical

Treatm

ent

Pharmaco

logical

Treatm

ent

Feed

ing Brea

st Milk

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

76% 76%

45%

59%

68%

49%

78%

83%

59%

66%

81%

55%

80%

88%

67%69%

84%

57%

90%

95%

76%

84%

92%

72%

Audit 1Audit 2Audit 3Audit 4

Centers: 181, 170,125, and 119 Audited. 22% Level A, 60% Level B, and 18% Level C.

Department of PediatricsSection of Neonatology

VONS DATA: Soll R. 2014

Infants: 1050, 991,797, and 620 Audited.


Morphine Methadone Clonidine Phenobarb DTO0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

82%

16%

7%

27%

4%

82%

15%

10%

24%

3%

82%

16%

9%

24%

4%

89%

11%9%

22%

0%

Audit 1Audit 2Audit 3Audit 4

Infant diagnosed with NAS

Maternal Exposure

OB service

Newborn Infants from Maternal Drug Use

Postpartum nursery team

•Identification•Screening (Antenatal visit, at labor admission)(universal vs risk based screening)•Prenatal education and expectation of neonatal outcome

NAS infants required Drug Rx and NICU admission

•Identification•Screening: universal vs risk based, methods of screening•Diagnosis: NAS scoring system•Management: NonePharmRx•Identified NAS infant require DrugRx based on NAS score

NICU•None PharmRx•NAS Scoring system•Initiation of drug Rx based on NAS score.•Wean and discontinue drug Rx based on NAS score.•Discharge disposition

WVUCH NAS Quality Improvement Project


Pregnant Mother

OB ANC

●Universal UDS: research project●Education●Referring to BMP

Labor

OB

●Universal UDS●Univeresal CTDS

Exposed NB infant

Postpartum Service

●NAS score (standardized)●Diagnosis of NAS●Provided ●NonePharmRx●Identify PharmRx Candidate based on clinical and NAS score

NICU admission

NICU●NAS score (standardized)Continue ●NonePharmRx●Initiate PharmRx and follow the NAS guideline

FLOW CHART


July 2012 Aug-Oct 2012

Nov –Dec 2012

Jan 2013 Feb 2013 March 2013 April 2013

Sep 2013 Oct 2013

WVU Children Hospital Neonatal Abstinence Syndrome Quality Improvement Committee was established. Chaired and leaded by Stephanie Greyson (second year Neo-fellow), and Courtney B. Sweet (NICU PharmD).

Distribution of work process to committee members.Screening process Scoring processDiagnostic criteria based on the NAS scoreNone pharmacological managementDrug of choiceCriteria to initiate pharmacological treatment Weaning and discontinue pharmacological treatment based on the NAS scoreDischarge criteria (both with and without pharmacological treatment

all the NICU nursing staff have gone to mandatory trained to use standardized NAS scoring system. General pediatric nursing preceptors and PICU nursing preceptor were also trained and become the trainer for their unit. The WVUCH guideline was distributed to all NICU attending, fellow, pediatric house staff, Pediatric and NICU PharmD, hospitalists and PICU attending.

WVUCH NAS guideline were launched and in effect.

universal MDS for every NICU admission was discussed. Meeting with clinical laboratory department resulted in the universal MDS.

All NICU admitted infants had universal MDS. Concern for missing MDS for postpartum normal newborn infants and unable to detect Buprenorphine from MDS were discussed. The option of obtaining universal cord tissue drug screen was discussed with the clinical laboratory department. The OB service agreed with universal cord tissue drug screening.

Universal cord tissue screening was started; Buprenorphine is part of the drug screened but not THC. OB department started “Maternal addiction screening” in antenatal care service and antepartum maternal education.

Standardize the NAS scoring process for OB postpartum nursing staffsCollecting and analysis the data over the past year

VONs QI meeting in Chicago: Data Presentation

Our Road Map

July 2014

Breast feeding and use of MBM for NAS infant guidelineParent Brochure and education for NASNon-pharmacological management re-education

WVUCH NAS Quality Improvement Project


Modified Finnegan Score: 1986, CNS, GI, Metabolic. VONS audit: 61% used


High Risk Neonate for NAS

Obtain Modified Finnegan Scale every 2-4 hr before feed after birth.

NAS if score ≥ 8 on two successive evaluations. Non-pharmacological

Management

NAS score ≥12 on three consecutive occasions, or combine consecutive NAS score of ≥28

OMS at 0.05 mg/kg/dose q 3 hr Two consecutive NAS score still ≥12, rescue dose of 0.025 mg/kg/dose and increase the dose to 0.075 mg/kg/dose q 3 hr

Dose escalation: If S&S of NAS persist or two consecutive NAS score >10, increase the dose to 0.075, 0.10 and 0.125 mg/kg/dose q 3 hr. Add phenobarb if need OMS more than 0.125 mg/kg/dose q 3 hr

Three days of stabilization and improvement of NAS

Weaning: all NAS score <10 for the past 24 hr. Reduce the total dose by 10% of stabilized dose every day. Wean the interval to q 4, q 6 and then q 8 hr every other day as tolerated (but keep the 10% total reduction).

Discharge: Total dose must be ≤30% of stabilized dose and the interval must be at least q 8 hr for 24 hr. Primary care provider must be notified and provided with weaning scale.

Cessation of treatment: Total dose must be ≤10% of stabilized dose. If the cessation occurs in the hospital, the infant must be observed for at least 24 hr after the OMS was discontinued.

(WVU Children Hospital Treatment Guideline for Neonate with NAS 2012)

Dose adjustment: Switching from OMS to morphine injection must be discussed with PedsPharmD as necessary


2012 20130.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

8.10%

9.20%

4.10%3.90%

NAS 779.5from MICC

NAS (779.5) WVUCH NICU 2012 and 2013

579 621Total NICU admission


2012 2013

MICC admission (n)1336 1405

Opioid exposure (n)code 760.72

87 (6.5%) 85 (6.0%)

Neonatal Opioid Withdrawal Syndrome (NOWS)

38/87 (43.7%) 57/85 (67.0%)

NOWS and NICU admission 24/38 (63.2%) 24/57 (42.1%)


NOWS infants ≥ 35 wk GA in NICU and treated.

2012 (n=8) 2013 (n=13) P value

Length of Stay (LOS) (day ± SD) 18.8 ± 4.9 15.5 ± 5.9 P=0.32

Length of Treatment (LOT) (day ± SD)

22.0 ± 7.5 14.4 ± 6.3 P=0.04


2012 2013

Max dose (mg/kg/day) 0.16-0.80 0.40-0.60

CPS involvement 12/23 (52.3%) 17/24 (70.8%)

Discharge home with parents

23/23 (100%) 22/23 (95.6%)

CTS 0/24 15/20 (7 bup, 4 methad)

UDS 3/24 1/1 (bup)

MDS 13/24 2/2 (1 methad)


CTDS: APRIL 2013 TO MARCH 2014TOTAL OF 1430 SPECIMENS TESTED.

Total Positive Drug Hit0

200

400

600

800

1000

1200

1400

1600

1430

230283

CTDS (April2013 to March2014)

CTDS (April2013 to March2014)

16.1% 19.8%


CTDS: APRIL 2013 TO MARCH 2014PERCENTAGE OF POSITIVE DRUGS

Opioids Bup/Metha Sedative Stimulant THC*0

2

4

6

8

10

12

8.4

2.6

3.3

1

9.8

Series1

* THC data: from October 2013 to March 2014


DRUG CLASS # of POS %POS %ALL

Opiates 120 47.5% 6.5%

THC* 64 25.2% 3.4%

Sedatives/Hypnotics 47 20.9% 2.8%

Buprenorphine & Methadone 37 18.0% 2.5%

Stimulants 15 2.9% 0.4%

283


WVUCH BREAST FEEDING AND USE OF MATERNAL BREAST MILK FOR NAS INFANTS• Absolute Contraindications:

– Evidence of active alcohol or drug abuse (illicit or prescriptive).

– HIV or HTLV-II positive.– Galactosemia– Maternal medications contraindicated in

lactation such as lithium, methotrexate, radioactive or immunosuppressive agent, antimetabolites and IV drugs of abuse.


WVUCH BREAST FEEDING AND USE OF MATERNAL BREAST MILK FOR NAS INFANTS• Absolute Contraindications:

– For mothers with a history of substance abuse or those receiving treatment in an opioid maintenance program and:

• Refusal of consent to speak with prescribing physician or treatment facility.

• Relapse with illicit drugs 30 days before delivery.• No plans to follow in substance abuse treatment

program.• Relapse of drug use after delivery.• Sobriety achieved and maintained only in inpatient

setting.Department of PediatricsSection of Neonatology

WVUCH BREAST FEEDING AND USE OF MATERNAL BREAST MILK FOR NAS INFANTS• Relative Contraindications:

– Perinatal providers, substance abuse providers, physicians, lactation consultants, NNP’s and nurses will work collaboratively to individually assess risks / benefits of breastfeeding in the following mothers:

• No, limited or late prenatal care.

• Women in treatment program, but relapsing 30 to 90 days prior to delivery.

• THC: Any patient with a positive screen for THC needs to receive counseling. During discussion providers should determine if use is acute, recreational, or chronic. Mothers should be encouraged to discontinue ALL use if she desires to breast feed. This discussion should be documented in baby’s chart.

• All maternal medications will be reviewed for lactation compatibility delivery.

• Untreated, symptomatic psychiatric issues or non-compliance of treatment.


NON-PHARMACOLOGICAL TREATMENT GUIDELINES FOR NAS WVU CHILDREN HOSPITAL

– Swaddle, Cuddle, Kangaroo care

– High caloric content formula (24 cal/oz) and frequent feeding.

– Feeding on demand: q 2-4 hr.

– Consider reduce the caloric content back to regular formula (20 cal/oz) when infant consumes volume more than 160 ml/kg/day.

– Place in a quiet, reduce stimulus environment etc.

– Consider using Infant Motion Soothing Machine.

– Consider early application of cream/paste to prevent perianal skin breakdown.


NAS NON-PHARMACOLOGICAL NURSING TOOL KIT


THE 5 S’S OF SOOTHING:HOW TO RAPIDLY CALM YOUR FRANTIC BABY

• Swaddling

• Side/stomach position

• Shushing sounds

• Swinging

• Sucking


OTHER NURSING INTERVENTIONS FOR NON-PHARMACOLOGIC TREATMENT OF NAS INFANTS

• Encourage Family to stay & Participate in cares; holding/cuddling, feeding, settling/console, changing diaper (promote bonding)– The parent is the best constant care giver: The more

the parent is here the better he/she will do– Teach them the 6 basic principles and 5 S’s

• Cluster Care• Gently Rocking• Swaddling tight & proper

– Swaddle with hands up or hands at side



• Hold close to body

• Decrease noise and lights

• Speak softly & remind those

visiting and around to use quiet

voices

• Protect from scratching/rubbing- use mittens or socks

• Patting buttocks/back gently & rhythmically



• Frequent Diaper changes

• Discuss with physician/NNP possibility of ordering aquaphor prior to breakdown

• Feed as ordered

• Support/Encourage Breast feeding

• Encourage kangaroo care

• Infant MassageDepartment of PediatricsSection of Neonatology


• Use of relaxation techniques• Use of Boppy, infant chair or Mamaroo• Pacifier/ Wubbanub• Soft linens to help reduce with excoriation• Soft gentle touch• Utilize ancillary staff

(CA's, PT, OT, cuddlers)


Standardized Pharmacologic Treatment of NAS: A Year in ReviewCourtney Sweet, PharmD, BCPS

Baseline Data• Timeframe: January 2009- December 2011• All infants admitted to WVU Children’s Hospital with an ICD-9

of 760.7x (Noxious influences affecting fetus or newborn via placenta or breast milk) or 779.5 (Drug withdrawal syndrome in newborns)

358 infants in total• 129 patient born at less than 37 weeks gestation• 155 patients born at 37 weeks or more and did not receive

morphine or methadone• 61 patients born at 37 weeks or more and received morphine

or methadone• 13 term infants excluded due to congenital heart of GI anomaly

Baseline Data- Treated• 39% (61/ 216) of term infants received pharmacologic therapy

• 60 infants received morphine (98%)• 2 infants received methadone (3.3%)

• Mean length of stay= 22 days (SD 10.7)• Median length of stay= 20 days (Range 5-61 days)

• 46 % of treated infants required a LOS greater than 21 days

• 5% of treated infants received any breast milk 24 hours prior to discharge

Timeline• July 2012 NAS Committee’s 1st Meeting • December 2012 NICU Nurses completed training on

Finnegans scoring tool • January 1st 2013 Treatment algorithm Go-Live January 1st

2013• February 2013 MICC Nurses completed training on Finnegans

scoring tool• June 2014 Parent education pamphlet distribution began• September 2014 Initiation of nursing education related to

non-pharmacologic care

1.5 YEARS AND COUNTINGJanuary 2013-June 2014

Demographics• Discharge Timeframe: January 2013- June 2014• All infants coded with 760.7x or 779.5

• 74 patients were treated with a pharmacologic agent• 63 patients born at 37 weeks or more and received morphine

or methadone

Treated Infants• All 63 patients (100%) received morphine therapy

For 37 term, treated infants:• Mean length of stay= 18 days (SD 5.3)

• Reduced 4 days from baseline• Median length of stay= 18 days (Range 8-36 days)

• Reduced 2 days from baseline• 2nd Quarter 2014 the median was 16 days

• 30% of treated infants required LOS greater than 21 days

• 14% of infants received breast milk 24 hours prior to discharge

ALGORITHM RESULTSAll patients (74 patients)

Medication Use• 100% of infants received morphine

• 84% (62 patients) received a stabilization dose of 0.05 mg/kg every 3 hours

• 11% (8 patients) received 0.075 mg/kg every 3 hours• 5% (4 patients) received 0.1 mg/kg every 3 hours• None received 0.125 mg/kg every 3 hours

• Average time stabilization dose utilized= 2.4 days• 8 patients weaned one day after stabilization dose

Medication Use• Average number of weaning steps required= 8.4

• (Min=2; Max= 17)

• 79% of infants discharged into the care of their parent(s)

• 35% of infants were discharged on morphine therapy

• 2 infant received phenobarbital

COMPLIANCE

15 months (1st Quarter 2013-1st Quarter 2014) 49 patients

Compliance• Morphine initiated for 3 consecutive scores greater than 12

• 46 patients started after admission• 78% met criteria to initiate morphine at time of initiation

• Morphine initiated at 0.05 mg/kg/dose every 3 hours• 89% received appropriate initial dose• 75% effectively stabilized on this dose

• Morphine increased for scores greater than 10• 9 patients (18%) were not increased for elevated scores

• Stabilization dose utilized for 3 days- 60% of patients• 84% utilized for 2-3 days

Compliance

1s

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Goal

Compliance with Treatment Algorithm

Percentage

Compliance• Addition of phenobarbital

• 2 patients – not compliant • 100% discharged at 30% of stabilization dose

Days0

0.5

1

1.5

2

Avg. Duration Between Weans

Compliant WeansNon-Compliant

p= 0.004

Outliers?• 10 patients required LOS > 21 days• Using Fisher’s exact and t-test comparing these patients to

patients with a LOS < 21 days Characteristic ≤ 21 days

(N= 27)> 21 days(N= 10)

p-value

Outborn 15 6 P= 1.0Parental custody 24 8 p= 0.59Use of breast milk 24 hours prior to d/c 6 0 p= 0.16Medication at discharge 12 1 p= 0.065Not increased with elevated scores 3 5 p= 0.02

Length of Stay

For term, treated infants (63 infants)• 71% of infants were discharged in 21 days or less

• Of note: 78% were discharged in 22 days or less

1s

t

2n

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Length of StayDays

What the Data Showed…• Initiate therapy for elevated scores (> 12); soothe for fussiness• Increase dose for elevated scores (consistently > 10)• Utilize stabilization dose for 3 days

• If excessive sleepiness occurs, consider weaning by 20% and document

• Wean according to guideline 10% and alternate between dose and interval changes

What We Have Learned…• Standardization of practice has led to a more consistent

treatment of infants with NAS• Length of stay and duration of therapy have been reduced

• Future directions• Formal education for all nursing staff related to non-

pharmacologic care• Focus on parent education and involvement in non-

pharmacologic care

effect of substance abuse on the mother and the newborn: experience of wvu healthcare collaboration...

Documents

shame slide

licsw slide

effect of substance

effects of substance

criminal activity slide

wv treatment

high risk

pregnancy prevalence