Opioids in Pregnancy and Beyond to Baby by Marcia W. VanVleet, MD, MPH Medical Director, Newborn Service Team, Women and Infants Hospital, and Assistant Professor of Pediatrics, Brown Alpert Medical School, Providence, RI. http://www.chaosmanorreviews.com/open_archives/jep _column-310.php National Alliance for Drug Endangered Children Webinar: June 13, 2012 Overview from General Info Medical Model Impact on the USA (numbers and costs) Set Expectations Neonatal Effects Establishing Exposure/ Testing Period of Observation/ Length of Stay Symptoms in Newborns Medical Treatment Treatment (Women & Infants model) Long Term Parental Reactions (similar to grieving) GENERAL INFO 1
Medical Model of Substance Abuse Substance abuse in pregnancy is a medical problem Can be associated with other diseases (Hep B, Hep C, HIV) Substance abuse has a lot of social and legal confounders States vary in how they approach substance abuse in pregnancy NAS: Impact on the USA? First estimate for the entire United States Discharge diagnosis Weighted How Common is NAS?.Increasing! Patrick, et al: NAS vs. Other Rate of Maternal Opiate Use 5 X s Rate of NAS 3 X s Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009 Trends in Neonatal Abstinence Syndrome JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951 2
What do these newborns look like? Patrick, et al: NAS vs. Other Weighted Characteristic in 2009 NAS n= 9,674 Other n= 1,113,123 ZIP: Lowest Income 36% 28% Highest Income 14% 21% No Difference: Insurance: Medicaid 78% 46% Gender Private 16% 48% Middle Income ZIP Hospital: Teaching 54% 44% Self-pay or other Children s 20% 12% Urban Hospitals Problems: Respiratory 31% 9% (88%) Low Birth Weight (<2500g) 19% 7% Feeding Difficulties 18% 3% Seizures 2% 0.1% Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009 Trends in Neonatal Abstinence Syndrome JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951 What does NAS cost us? Patrick, et al: NAS vs. Other Length of stay did not change over the years NAS: 15.8 16.4 days (P =.06) Other: 3.1 3.3 days (P <.001) Hospital cost increased incrementally (in 2009$) NAS: $39,400 $53,400 (P <.001) Other: $6,500 $9,500 (P <.001) Shifts in % of NAS costs From Self-Pay & Other to Medicaid (69% to 78%) Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009 Trends in Neonatal Abstinence Syndrome JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951 SET EXPECTATIONS NEONATAL EFFECTS 3
NAS: Establish Exposure Risk Inadequate prenatal care < 4 prenatal visits, late transfer of care, late initiation of care Result of screening survey e.g. 4P: Pregnancy/Past/Partner/Parents Clinical Concerns Known history within the last year both licit and illicit Toxicology Testing Substance Urine Drug Screen (UDS-6) Urine Drug Screen (UDS-8) Meconium (MDS) Amphetamine X X X Barbiturate X X Benzodiazepine X X Cannabinoid X X Tetrahydrocannabinol Carboxylic Acid Cocaine X X X * Opiate (s) X X X (s) Methadone Buprenorphine N.B. would need to add Hydrocodone and Oxycodone to UDS, and Methadone/Buprenorphine to MDS, *= metabolite X X X Timing of Withdrawal Period of Observation Early Onset Alcohol: 3-12 hrs Heroin: 4-25 hrs Cocaine: 1-2 days Late Onset Buprenorphine: Appears in 12-48 hours Peaks at 3-4 days Duration 5-7 days Methadone: 48-72 hrs (up to 4 wks) Barbiturates: 4-7 days (range 1-14 days) Hypnotics: up to 12 days SSRI: few days-1 month 4
Newborn Outcomes MOTHER Study Methadone Buprenorphine n=73 n=58 Treated for NAS 57% 47% Birth weight, gm 2879 3094 Infant LOS, days 17.5 +/- 1.5 10.0 +/- 1.2 Treatment, days 9.9 +/- 1.6 4.1 +/- 1.0 Jones et. al. Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure NEJM 2011; 363: 2320-31 Presentation of NAS Related to: the substance(s) and when exposed somewhat to dose but not predictable how mom metabolizes the substance gestational age ( preterm? less measurable) Onset by 48-72 hours More severe with methadone than heroin Symptoms in Newborns http://www.healingtalks.com/health/newborns-addicted-ondrugs-at-birth-a-new-epidemic/ 5
http://newborns.stanford. edu/photogallery/suckin greflex1.html http://newborns.stanford. edu/photogallery/jittery 3.html Neurological Autonomic NAS Symptom Scoring: Finnegan scores GI http://emedicine.medscape.com/article /978763-clinical#a0217 Video of Newborn with NAS Listen/ Watch for: Cry Jitteriness Excoriation Example of Scoring http://vimeo.com/10038566 6
SET EXPECTATIONS MEDICAL MANAGEMENT NAS: Inpatient Management Monitor: Objective Scoring (every 2-4 hours from birth to min. 72) Daily weights and intake/output ( calorie formula) Developmental needs (Occupational Therapy consult) Start other interventions on admission: Environment low lighting, low noise, skin to skin contact Care/ Parent Education swaddling, pacifier use cluster care (follow infant cues) breastfeeding best (few exceptions) infant massage NAS: What Med to Use? Should be guideline based Use objective scoring Vary by site Most use An opiate (morphine or methadone not paregoric) +/- Adjunct (Phenobarbital, clonidine, etc) No proven best 7
NAS at WIH: Medical Management Medications: Morphine and Phenobarbital should be used simultaneously for opiate withdrawal. (J Pediatr 2002;140:561-4) Coyle, et al: Opiate only vs. With Phenobarbital The duration of hospitalization was reduced by 48% (79 to 38 days) (P <.001) Hospital cost per patient reduced by $35,856 (P <.001) Spent less time with severe withdrawal (P <.04) More time with mild withdrawal (P <.03) Required a lower maximum daily opiate dose (P <.009) (J Pediatr 2002;140:561-4) NAS: Management with Medication Start & increase morphine NAS/Finnegan s 8 on 3 consecutive or 12 on 2 Manage morphine hold Capture dose for 48-72 hours before weaning wean in regular increments observe off morphine for 48 hours prior to discharge Phenobarbital as an adjunct to morphine obtain Phenobarbital levels will go home on Phenobarbital, wean by weight 8
NAS: Outpatient Management D/C planning begins upon admission encourage parental involvement (extend to foster care) educate on infant comfort measures and medication administration Follow-up: Outpatient visiting nurse (VNA) referral PCP/PMD within 7-10 days after discharge Consider: Developmental follow-up program in 3-4 weeks Early Intervention NAS: Long Term Outcomes No definitive studies Most find no long term differences but certainly at risk (especially learning and behavior) Combination of in utero exposure/ postnatal environment/ biology (genetics) Hudak et. al. Confounding variables such as environment and dysfunctional caregivers, complicates the interpretation of outcomes. Hudak, ML, RC Tan and the Committee on Drugs and the Committee on the Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics 2012;129;e540. PARENTAL REACTIONS 9
Not Like a Regular Stay Parent Reactions Increase maternal guilt Prolonged hospitalization Separation? limit maternal bonding Difficulty explaining to others Dependent on Expectations and Previous Experiences Denial Anger The Kübler-Ross Five Stages of Grief "I feel fine." "This can't be happening, not to me." "Why me? It's not fair!" "How can this happen to me?" '"Who is to blame?" Bargaining "I'll do anything for. Parental Reactions in the Nursery The baby is fine. Mom can t leave without the baby. We weren t told it was a problem. The scores are wrong. You can t keep my baby! What if I came in and held my baby all day long? Depression "I'm going to die soon so what s the point?" Acceptance "It's going to be okay." "I can't fight it, I may as well prepare for it." I can t sleep. I can t get to the hospital. This is the best for the baby. http://en.wikipedia.org/wiki/k%c3%bcbler-ross_model Kübler-Ross, E. (1969) On Death and Dying, Routledge, ISBN 0415040159 Take Home Message about NAS Multidisciplinary Medical Approach Establishing the Exposure(s) Setting Clear Expectations & Communication Keeping Families Engaged in Treatment 10
Questions, Comments, Concerns.? We welcome your feedback! THANK YOU! mvanvleet@wihri.org From: Thought Action Group found at http://therealmichaelfox.wordpress.com/ Helpful Resources Screening: 4 P s This screening device is often used as a way to begin discussion about drug or alcohol use. Any woman who answers yes to one or more questions should be referred for further assessment 1) Have you ever used drugs or alcohol during the Pregnancy? 2) Have you had a problem with drugs or alcohol on the Past? 3) Does your Partner have a problem with drugs or alcohol? 4) Do you consider one of your Parents to be an addict or alcoholic? Ewing H, Born Free Project, Martinez California 11
The 'TWEAK' Test Screening Question: Do you drink alcoholic beverages? T Tolerance W Worry How many drinks does it takes to make you feel high? ( score for two or more) 2 points Have close friends worried or complained about your drinking in the past year? 1 point Do you sometimes take a drink first thing in the E Eye opener morning? A Amnesia K Cut down Has anyone ever told you about things they you said or did while you were drinking that you could not remember? 1 point 1 point Do you sometimes feel the need to cut down on your drinking? 1 point 7 points Scoring: A total score > three points indicates the person is likely to be a heavy drinker Nevin et al. BMC Family Practice 2002 3:2 doi:10.1186/1471-2296-3-2 References American Academy of Pediatrics, Committee on Drugs. Use of psychoactive medication during pregnancy and possible effects on the fetus and newborn. Pediatrics Vol. 105 No. 4 April 2000, 880-887. Coyle MG, Ferguson A, Lagasse L, Oh W, Lester B. Diluted Tincture of Opium (DTO) and Phenobarbital versus DTO alone for neonatal opiate withdrawal in term infants. J Pediatr 2002;140:561-4. Coyle MG, Ferguson A, Lagasse L, Liu J, Lester B. Neurobehavioral effects of treatment for opiate withdrawal. Arch Dis Child Neonatal Ed. 2005;90:F73-F74. Hudak, ML, RC Tan and the Committee on Drugs and the Committee on the Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics 2012;129;e540. Finnegan LP, Connaughton JF, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment and management. Addict Dis 1975;2:141-58. Lester BM, Tronick EZ. (Eds.) The neonatal intensive care unit network neurobehavioral scale (NNNS). Supplement to Pediatrics, Vol 113 March 2004, 631-699. Lester BM, Andreozzi L, Appiah L. Substance use during pregnancy: time for policy to catch up with research. BMC Harm Reduction Journal (2004) 1:5 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc419718/pdf/1477-7517-1-5.pdf Patrick SW, et al. Neonatal Abstinence Syndrome and Associated Health Care Expenditures United States, 2000-2009. JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951 12