Neonatal bstinence Syndrome Questions & nswers Webinar #1 (February 9, 2012) Webinar #2 (March 30, 3012) For more information and to download a copy of the NS Clinical Practice Guidelines, please visit us online at: http://pcmch.on.ca/clinicalpracticeguidelines/neonatalbstinencesyndrome.aspx Q 1 Can we print and share the presentation with our colleagues? Yes. The PowerPoint presentation and clinical guidelines are available on the PCMCH website. We encourage you to share the on-line documents with your colleagues. Q 2 Q 3 What is the scope of the NS clinical practice guidelines? The NS guidelines were written to address the psychosocial needs of opioid dependent women during the preconception, antenatal and postpartum/post discharge stages as well as the assessment and treatment of infants born to these women. These guidelines focus on NS resulting from opioid dependence and do not address the management of NS resulting from the use of selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, barbiturates, ethanol, sedatives or hypnotics. What is the opinion on screening for drugs at the beginning of the pregnancy? Would this scare the mothers off before getting the prenatal care that they need? Health care providers should routinely ask all women of childbearing age about use of medicinal and non-medicinal substances including alcohol, opioids and other analgesics, selective serotonin reuptake inhibitors (SSRIs) and tobacco use. Routine universal screening by primary health care providers is important to normalize conversation about this important and sensitive topic. Pregnancy is a time when a woman is most willing to make lifestyle changes for the wellbeing of her baby, therefore assessment and counselling about substance use is important at this time. Harm reduction models of care promote positive change and even small changes should be celebrated as a means to empower these women. Q 4 Q 5 Why is contraceptive counselling important for women beginning a methadone maintenance program? Contraceptive counselling is essential to prevent unplanned pregnancy when a woman switches from short acting opioids, which suppress ovulation, to a long acting opioid such as methadone or burprenorphine. Has PCMCH thought about having a narcotic registry to provide data about narcotic use? The MOHLTC s Ontario Narcotic Strategy introduced legislation to support the development of the Neonatal bstinence Syndrome Webinar (Feb. 9 & March 30, 2012): Questions & nswers Page 1 of 5
Narcotics Monitoring System, expected to be operational in the spring of 2012. It will provide a database for the collection and storage of information on prescribing and dispensing activities relating to prescription narcotics and other controlled substances in Ontario. Q 6 Q 7 Q 8 Q 9 Q 10 Q 11 Q 12 Q 13 n increasing number of newborns are at risk of NS due to maternal SSRI/SNRI use. Does PCMCH plan to address this in the future? This will be considered in the future but is not part of PCMCH s 2012-13 work plan. How is withdrawal from methadone different than with oxycontin or other narcotics? Methadone is a long acting opioid and therefore has a longer half life than other narcotics. Symptoms of methadone withdrawal may not occur until 48-72 hours after birth and can be delayed up to 4 weeks. In infants exhibiting withdrawal symptoms from Methadone after more than 30 days, are they actually withdrawing from Methadone or are there other issues at play? It is possible for Methadone withdrawal to be delayed until 30 days after birth. This would likely occur in babies who are particularly slow to metabolize methadone. nother factor that could affect this is the cessation of or reduction in breastfeeding. If there is no change in outcome in the newborn between Methadone dosages in women, is there a goal to decrease the dose during pregnancy? The goal during pregnancy is to maintain women on an appropriate dose that keeps them comfortable 24 hours per day. Based on a meta-analysis, the maternal methadone dose is not related to the severity of neonatal withdrawal. Therefore women should focus on achieving a dose that eliminates withdrawal symptoms and cravings (i.e. to maintain abstinence from other opioids and other illicit drugs). Reducing the dose is not needed, especially since methadone metabolism increases towards the third trimester and the dose will need to be increased in response to new onset of withdrawal symptoms. What is the incidence of drug addiction in adulthood when an infant with NS was exposed at birth, especially when removed from the maternal social situation? The incidence of NS was not as high 20 years ago as it is currently; therefore there is no conclusive evidence at present regarding long-term outcomes for these infants. There have been some studies in the United Kingdom looking at the impact of co-factors in children raised in foster homes. What are the special accommodations for burprenorphine for pregnant clients in regards to it being funded and/or prescribed? In Canada, Buprenorphine is only available through Health Canada s Special ccess program and only during pregnancy. If approved, it is sent to hospital pharmacies and then supplied either for inpatients or at outpatient clinic appointments. There is no cost for the patient. Can you recommend V resources for staff training purposes? The expert panel did not review training videos and therefore does not recommend a specific resource. What impact does substance use and NS have on Northern Ontario? Neonatal bstinence Syndrome Webinar (Feb. 9 & March 30, 2012): Questions & nswers Page 2 of 5
Q 14 Q 15 Q 16 Q 17 Q 18 Q 19 Q 20 The management of substance use and NS is particularly problematic in Northern Ontario. Many First Nations communities have identified a state of emergency regarding the abuse of prescription narcotics. The vast geographical area of the North encompasses multiple remote communities that rely on a nursing station for health care support with few, if any, local family physicians. They rely on distant regional hospitals for their acute healthcare needs. The need to receive healthcare away from home contributes to isolation, lack of support and limited resources. lthough methadone maintenance is considered the optimal treatment for opiate addiction in pregnancy, many of the remote communities lack access to methadone maintenance therapy and therefore women continue to struggle with opiate addiction throughout pregnancy re pregnant women from northern communities flown south for methadone maintenance treatment (MMT)? Currently there is no standard practice for those living in remote Northern communities. Some women relocate for MMT however housing and financial resources are a major concern for them. If the mother s urine tested positive for THC, what is your recommendation for breast feeding? Is it the mother s choice, taking into account the issues of socio-economic status (poverty and nutritional needs) and the lack of concise evidence about the risk to the baby? Breastfeeding is not recommended for women using illicit drugs until sobriety is reached therefore they should be advised to pump and discard their breast milk while they are using marijuana. Discussing this in the antenatal period is paramount so the woman can prepare to wean herself from illicit drug use. Periodic drug screening while the woman is breastfeeding is indicted to monitor for relapse. If a hospital has a pre-printed order set for the infant at risk for NS, does PCMCH recommend they change to a medical directive? medical directive is only one method to facilitate the timely collection of urine and meconium samples for toxicology screening for the infant with suspected or confirmed NS. Signed, pre-printed orders may also meet this need. Is there any time when urine or meconium testing can be done without consent? There is no clear legal opinion regarding consent for testing. Each hospital should follow their existing protocol for consent for testing urine and meconium. Hair testing requires consent. Is maternal consent required for testing? There is no clear opinion regarding consent for testing. Each hospital should follow their existing protocol for consent for testing urine and meconium. Hair testing requires consent. PCMCH has contacted the OH for advice regarding whether or not it is possible to have a single legal opinion for all Ontario hospitals regarding the consent issue. When do you suggest isolated hospitals initiate transfer of an infant with NS to a tertiary hospital? Transport should be initiated as soon as a baby at risk of NS is born if the isolated hospital is not in a position to care for the infant. What is the recommended first choice of treatment for polydrug withdrawal, phenobarb or Neonatal bstinence Syndrome Webinar (Feb. 9 & March 30, 2012): Questions & nswers Page 3 of 5
morphine? Q 21 Q 22 Q 23 Morphine should be considered the first line pharmacologic treatment of NS when supportive measures fail to adequately ameliorate the signs of withdrawal. Has there been research into the validity of the Finnegan Scoring system for older infants? In 2009, Jansson et al identified that older infants may have shorter periods of sleep than newborns. However they are capable of maintaining a quiet alert state. The study recommended that time spent in a quiet and organized state be included in total sleep for that scoring interval. Is it beneficial for the infant with NS to room-in with the mother? Rooming-in is beneficial and should be encouraged as it supports the practice of mother-baby dyad care. When pharmacological treatment is necessary transfer to the Special Care Nursery/NICU is required. Parental involvement in care in the NICU/SCN should be encouraged and supported. Is it safe for substance using women to breastfeed? Breastfeeding is not recommended for women using illicit drugs until sobriety is reached. These women should pump and discard their breast milk to establish and maintain their milk supply. Occasional use of the following substances may be of concern and mothers who use these substances in short episodes should avoid breastfeeding temporarily during this time. Substances causing concern include ecstasy, crystal meth, amphetamines, cocaine and related stimulants, alcohol, opioids, benzodiazepines and cannabis. Q 24 Q 25 t what point is Phenobarb introduced? Phenobarb is introduced when withdrawal symptoms are not adequately controlled by Morphine. Some centres use Clonidine instead of Phenobarb. See Pharmacological Treatment Protocol http://pcmch.on.ca/linkclick.aspx?fileticket=jtt9lpgebn0%3d&tabid=40 When on Morphine how long to do you leave the baby on monitoring? Cardio-respiratory monitoring is recommended for all infants starting on morphine and is continued for 4 days and/or until the dose is reduced. Further monitoring should then be at the discretion of the responsible physician. The goal is to ensure that the doses are not increasing but are decreasing and/or stabilized. Q 26 Q 27 What does cardio-respiratory monitoring include? Cardio-respiratory monitoring includes heart rate and respiratory rate and excludes ECG and oxygen saturation Can cardio-respiratory monitoring be done outside the SCN/NICU setting? Yes, cardio-respiratory monitoring can be done in any setting where the nurses are competent in managing the care of an infant receiving morphine, including cardio-respiratory monitoring. paediatric unit is sometimes used as an alternative care setting. Neonatal bstinence Syndrome Webinar (Feb. 9 & March 30, 2012): Questions & nswers Page 4 of 5
Q 28 Q 29 Q 30 Q 31 Q 32 Is it necessary for all infants with NS to remain in hospital throughout the weaning process? Discharging the infant with NS home on morphine should only be undertaken if the clinical team is confident that the social risk is low, the infant is stable, and there is a clear and comprehensive plan for weaning the infant and planned supervision of the infant during weaning. When weaning from morphine, is the dose reduced by 10% of the total daily dose, or 10% of the original dose of morphine. The dose used to wean the infant from morphine is based on 10% of the total daily dose. See the NS Pharmacologic Treatment Protocol dosing guidelines. What role does public health play in the support of infants with NS and their family after discharge? Public Health, including Healthy Babies/Healthy Children and sexual health clinics, provides important support for substance using women during pregnancy as well as support for mothers, infants and their families post discharge. What is your definition of polydrug exposure? Polydrug exposure refers to exposure to more than one addictive drug or substance. Is there an information-sharing site to discuss dosing and length of stay data? re there any sites auditing the peak dose of Morphine? There is currently no such information site but CIHI continually collects data on the average LOS by site. review of practices across the province was carried out when the expert panel was convened but no information on peak doses was obtained. Individual hospitals are able to acquire their own data through chart audits or pharmacy records. Neonatal bstinence Syndrome Webinar (Feb. 9 & March 30, 2012): Questions & nswers Page 5 of 5