neonatal abs,nence syndrome - omed 2017 · neonatal abs,nence syndrome how we got here and where we...

NeonatalAbs,nenceSyndromeHowWeGotHereandWhereWeAreGoing

KathrynZiegler,DO,FAAPNewbornSpecialCareAssociates

AbingtonJeffersonHealth

Disclosures

•  Ihavenofinancialdisclosures•  Wewilldiscusstheuseofmorphineininfantswhichisanofflabeluse

Objec,ves

•  Discusstheincidence/epidemiologyofopioiduse

•  Discusstheincidence/epidemiologyofNeonatalAbs,nenceSyndrome

•  DiscusstreatmentstrategiesforNeonatalAbs,nenceSyndrome

•  DiscussQualityImprovementEffortsforNeonatalAbs,nenceSyndrome

Opioids

•  Natural,endogenousandsynthe,c•  BindµreceptorsinCNS– Supraspinalanalgesia– Seda,on,euphoria,miosis,respiratorydepressionanddecreasedGImo,lity

– Prolongedusecausesphysicalandpsychologicaldependence

OpioidReceptors

Opioids

•  Natural– Morphine(extractedfromopium)

•  Synthe,c– Codeine,heroin,hydromorphone,fentanyl,methadone

•  Endogenous– Enkephalins,endorphins,endomorphins

TheProblem

•  Overdosedeathrateincreasedby137%since2000– 200%increasedindeathfromopioidoverdose

•  Americansconsume80%ofglobalopioidsupply– 99%ofhydrocodonesupply

•  Heroinoverdoseshavetripledinlast4years– Pastmisuseofprescrip,onopioidsclearlylinked

Manchinka,,etal

IncreasingDeathfromOpioids•  Sex:

•  Males(7.6%)•  Females(4.7%)

•  Age•  25-34yearolds(10.5%)•  35-44yearolds(8.7%)•  55-64yearolds(5.7%)•  ≥65yearolds(7.7%)

•  Race•  White,nonhispanic(8%)•  Black,nonhispanic(8.2%)

•  Geography•  Northeast(8.8%)•  Midwest(9.6%)•  South(6.9%)

Rudd,R.A.etal

IncreasesinDrugandOpioidOverdoseDeaths—UnitedStates,2000–2014

AmericanJournalofTransplantaConVolume16,Issue4,pages1323-1327,22MAR2016DOI:10.1111/ajt.13776hgp://onlinelibrary.wiley.com/doi/10.1111/ajt.13776/full#ajt13776-fig-0002

TheProblem

1986Publica,onthatopioidscanbeusedin

peoplewithoutcancer

andpain

1996AmericanPain

SocietyTradmarkspainasthe5thVS

1996

PurduePharmareleasesoxycon,n

1998VA/JCHAO

makepain5thVS

1998Federa,onofStateMedicalBoards-Drscan

safelyRxnarco,cs

TheProblem

2001JCHAOissuesstandardsurging

hospitalstoregularlyaskpa,entsabout

pain

2001JCHAO

publishesguidetoaddressphysician

concernsaboutaddic,onandtolerance

2007Purdue

Pharmapleadsguiltyto

misbrandingofoxycon,n

2012259

millionopioidRxwrigen$9billion

2013Opioiddeathssurpasscaraccidentsas

leadingcauseofaccidentaldeath

TheProblem

•  Pregnantwomendonotescapethereachofopioidaddic,on– 4.5%ofpregnantwomenreportusingillicitdrugs

•  InfantsborntowomenonopioidsareatriskofNeonatalAbs,nenceSyndrome(NAS)

•  300%increaseinNAS(2000-2013)– 1.5à6cases/1000hospitalbirths

hgps://www.cdc.gov/mmwr/volumes/65/wr/mm6531a2.htm

TheProblem

Source:Patrick,etal.JournalofPerinatology2015

Source:PennsylvaniaHealthcareCostContainmentCouncil

PennsylvaniaData

Source:PennsylvaniaHeatlhcareCostContainmentCouncil

PennsylvaniaData

TheProblem

•  Pennsylvaniabythenumbers(2000-2015)– Neonatalstaysrelatedtosubstanceabuse

• é250%(6.5à19.6/1000neonatalstays)

– Neonatalabs,nencesyndrome• é870%(1.6à16/1000neonatalstays)

– Cost•  28,000days•  $20million

NeonatalAbs,nenceSyndrome

•  Constella,onofsymptomsseenininfantswhoareexposedtoopiatesinutero

•  Somevaria,oninonsetandseverityofsymptoms–  Timingofmostrecentdrugusepriortodelivery– Maternalmetabolism–  Placentalmetabolism–  Infantmetabolism/excre,on–  Concomitantuseofotherdrugs/substances


•  55-94%ofinfantsexposedinuteroexhibitsymptoms

•  Seldomeffectsinfants<34weeksgesta,on

OpioidReceptors

OpioiduseinPregnancy

•  Opioidsaresmall,lipophilic,lowmolecularweight– Crossplacentalandbloodbrainbarriers

•  Detoxifica,onassociatedwithincreasedriskoffetaldistressandloss


•  CNSsymptoms– Con,nuousand/orhigh-pitchedcrying– Difficultysleeping– Hyperac,veMoroReflex– Tremors– Hypertonicity– Skinexcoria,on– Generalizedconvulsions/seizures


•  AutonomicSymptoms– Temperatureeleva,on– Sneezing/nasalstuffiness– Mogledskin– Tachypnea– Swea,ng– Yawning


•  Gastrointes,nalsymptoms– Feedingdifficul,es

•  Unabletoorganizetofeed•  Bi,ngnipple•  Lackofcoordina,on

– Frequentwatery/loosestools•  Leadstoskinbreakdown

– Regurgita,on– Excessivesucking– Failuretothrive


Substance OnsetofSymptoms

Heroin Birth–3days

Methadone/buprenorphine

Birth–7days(subacutesignsupto6months)

Benzodiazapene Hours-2weeks

NonNarco,cSubstanceExposure

•  Cocaine– Nowithdrawal

•  NEC,abrup,on,fetaldistressandIUGR

•  Alcohol– Hyperac,vity,tremors,poorsuck,hyperphagia– Sxatbirth

•  Caffeine–  Jigeriness,bradycardia,vomi,ng,tachypnea– Sxatbirthandfor1-7days


•  Barbiturates– Similartoopioids– Sxatbirthupto14days

•  SSRI’s–  Irritability,tremors,poorsuck,feedingdifficul,es,hypertonia,fever,hypoglycemia,seizures

– Sxhourstodays


•  Benzodiazapene– Similartoopioids

•  Hypo/hypertonia•  Poorsuck•  Hypothermia•  Apnea•  Tremors•  Vomi,ng•  Tachypnea

– Onsethourstoweeks

Differen,alDiagnosis

•  Sepsis– meningi,s

•  Electrolyteabnormality•  Hematologicirregulari,es•  Perinatalasphyxia•  Intracranialpathology

Diagnosis

•  History,history,history– Maternalmedical,familyandsocialhistory– Pregnancyhistory– Birthhistory

•  Labs– Cbc,bmp,+/-bloodculture(ifillappearing)– Urine/meconiumdrugscreens

•  Risk/benefitevalua,on– RarelyLPifhistoryc/wNAS

Drugtes,ng

•  IdeallyUDSfrommotheronadmission•  InfantUDS(preferablyfirstvoid)•  InfantMeconiumdrugscreen– Reflectsexposurefrom20weeksGA– Collectfirsttwosamples

•  Infanthair•  Umbilicalcord,ssue

MaternalUrineToxicology

Source:PEDIATRICSVolume129,Number2,February2012

Poten,alFalsePosi,ves

Source:PartnershipHealthPlanofCalifornia,2015

PhysicalExam

•  Hypertonicity– Globalvs.extremi,es– Headlag– Ventralsuspension

PhysicalExam

•  Skin– Mogling– Diaperarea– Excoria,on

Assessment

•  FinneganScoring– DevelopedbyDr.LoregaFinneganin1975– Providesquan,ta,veassessmentofNAS– PredominanttoolusedinUnitedStates– Usedfortermneonates<3weeksofage

UsingtheFinneganScore

•  Beginscoringwheninfantsshowsignsofwithdrawal– Scoreq3-4hours,auerfeedswheninfantatbest

•  Start“treatment”when3scores≥24or2scores≥24oronescoreof≥14

Treatment

•  Nonpharmacologic– Swaddling– Holding,rocking,swaying– Quiet,dark,nons,mula,ngenvironment– Encourageroomingin

•  Extendedfamily

BreasxeedingandNAS?

•  YES!!!–  Ifmotherisinatreatmentprogram– UDSisposi,veonlyformethadone/buprenorphine

•  AssociatedwithlesssevereNASthatpresentslaterandislesssevere

•  Lessfrequentlyrequirespharmacologicinterven,on

BreasxeedingandNAS

•  Smallamountsmethadone/buprenorphinesecretedintobreastmilk

•  Longtermneurodevelopmentalinforma,onnotavailable

•  Notenoughdatatodiscouragebreasxeeding•  Frankdiscussionwithmotheraboutslowweaning

PharmacologicTreatment

•  83%ofcliniciansintheUnitedStatesuseanopioidasthedrugoffirstchoice– MorphineorMethadone

•  Phenobarbitalismosttypicalsecond-linedrugifopiatedoesnotcontrolsymptoms

•  Clonidineasadjunc,vetherapyalsoanop,on•  Alsoconsiderusingmethadone

QualityImprovement

•  Recentlymul,plestudieshavesurfacedlookingatthecareofNAS

•  FocusondecreasedLOS– Decreasedcost

•  Standardiza,onoftreatments•  NASEduca,on•  RoomingIn

NASatAbingtonHospital

•  AbingtonHospital– 8milesnorthofPhiladelphia–  Approximately5000deliveries/year– 34bed;Level3bNICU

•  Increasingopioidexposedinfants•  NAStaskforceformedin2014

NASatAbingtonHospital

•  PreData–  June2013-June2015– 101infantswithposi,veUDS/MDS– 36infantsrequiredtreatmentwithmorphine– LOSwithNAS22.4days– LOSwithoutNAS4.1days

37

9

2

25

25

17

82

Methadone

Cocaine

PCP

Oxycodone

Opiates

MJ

Benzo's

Barbituartes

AbingtonHospital-Posi,veDrugScreen

AbingtonHosp,al–JeffersonHealthProtocol

PostData

•  July2015-May2016– 38babiesopioidexposed– 18babiestreatedforNAS– LOS16.8days

FutureDirec,ons

•  YaleNewHavenChildren’sHospital•  Standardiza,onofnonpharmacologic

care•  Parentaleduca,on•  NovelAssessmentApproach•  Morphineprn•  BypassingtheNICU

•  NovelApproachtoNAS•  Func,onalAssessment•  Abilitytoeat•  BFeffec,velyortake>1oz/feed

•  Abilitytosleep•  Undisturbed>1hour

•  Abilitytobeconsoled•  Within10minutes

•  NovelapproachtoTreatment•  Ifonscheduledmorphine•  10%weanTID

•  Auermaximumnonpharmacologicinterven,ons•  1doseofmorphinegiven(0.05mg/kg)•  Reassesed3hourslater•  Ea,ng,sleepingandconsolingwell•  Nofurtherdoses

•  55infantspreimplementa,on•  44infantspostimplementa,on–  LOS:22.4à5.9days–  PharmacologicTx:98%à14%–  Costs:$44,000à$10,000–  Noreadmissions,noadverseevents

Summary

•  Opioidaddic,oniscurrentlyanepidemic•  Pregnantwomencanbeaddicted•  NeonatalAbs,nenceSyndrome–treatmenthasbeenstablethroughtheyears

•  Breastfeedwhenable•  AssessmentchangehasnoADRs•  Nonpharmacologictreatmentisfeasible

Acknowledgements

•  NASTaskForceatAbingtonHospitalJeffersonHealth

•  MoiraWinstanley,NNP-BC•  AndrewLoh,MD

Thankyou!

ReferencesAs,,L.,Magers,J.S.,Keels,E.,Wispe,J.,&McCleadJr,R.E.(n.d.).AQualityImprovementProjecttoReduceLengthofStayforNeonatalAbs,nenceSyndrome.hgps://doi.org/10.1542/peds.2014-1269Corr,T.E.,&Hollenbeak,C.S.(2017).Theeconomicburdenofneonatalabs,nencesyndromeintheUnitedStates.Addic%on,112(9),1590–1599.hgps://doi.org/10.1111/add.13842Grossman,M.R.,Berkwig,A.K.,Osborn,R.R.,Xu,Y.,Esserman,D.A.,Shapiro,E.D.,&Bizzarro,M.J.(2017).AnIni,a,vetoImprovetheQualityofCareofInfantsWithNeonatalAbs,nenceSyndrome.Pediatrics.Retrievedfromhgp://pediatrics.aappublica,ons.org/content/early/2017/05/16/peds.2016-3360Holmes,A.V.,Atwood,E.C.,Whalen,B.,Beliveau,J.,Jarvis,J.D.,Matulis,J.C.,&Ralston,S.L.(n.d.).Rooming-IntoTreatNeonatalAbs,nenceSyndrome:ImprovedFamily-CenteredCareatLowerCost.hgps://doi.org/10.1542/peds.2015-2929

ReferencesInGuiltyPlea,OxyCon,nMakertoPay$600Million-TheNewYorkTimes.(n.d.).RetrievedSeptember6,2017,fromhgp://www.ny,mes.com/2007/05/10/business/11drug-web.html?mcubz=1Johannes,C.B.,Le,T.K.,Zhou,X.,Johnston,J.A.,&Dworkin,R.H.(2010).ThePrevalenceofChronicPaininUnitedStatesAdults:ResultsofanInternet-BasedSurvey.TheJournalofPain,11(11),1230–1239.hgps://doi.org/10.1016/j.jpain.2010.07.002Ko,J.Y.,Patrick,S.W.,Tong,V.T.,Patel,R.,Lind,J.N.,&Barfield,W.D.(2016).IncidenceofNeonatalAbs,nenceSyndrome—28States,1999–2013.MMWR.MorbidityandMortalityWeeklyReport,65(31),799–802.hgps://doi.org/10.15585/mmwr.mm6531a2Manchikan,,L.,&Singh,A.(2008).Therapeu,copioids:aten-yearperspec,veonthecomplexi,esandcomplica,onsoftheescala,nguse,abuse,andnonmedicaluseofopioids.PainPhysician,11(2Suppl),S63-88.Retrievedfromhgp://www.ncbi.nlm.nih.gov/pubmed/18443641

ReferencesMcQueen,K.,&Murphy-Oikonen,J.(2016).NeonatalAbs,nenceSyndrome.NewEnglandJournalofMedicine,375(25),2468–2479.hgps://doi.org/10.1056/NEJMra1600879MODELPOLICYONTHEUSEOFOPIOIDANALGESICSINTHETREATMENTOFCHRONICPAIN.(2013).Retrievedfromhgp://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/pain_policy_july2013.pdfMorone,N.E.,&Weiner,D.K.(2013).Painasthefiuhvitalsign:exposingthevitalneedforpaineduca,on.ClinicalTherapeu%cs,35(11),1728–32.hgps://doi.org/10.1016/j.clinthera.2013.10.001NeonatalandMaternalHospitaliza,onsRelatedtoSubstanceUse.(n.d.).Retrievedfromhgp://www.phc4.org/reports/ResearchBriefs/neonatal/092716/docs/researchbrief_neonatal_2000-2015.pdf

ReferencesPatrick,S.W.,Davis,M.M.,Lehmann,C.U.,Cooper,W.O.,Cooper,W.O.,Lehman,C.U.,&Cooper,W.O.(2015).NoTitle,35(8).hgps://doi.org/10.1038/jp.2015.36Rudd,R.A.,Aleshire,N.,Zibbell,J.E.,&MaghewGladden,R.(2016).IncreasesinDrugandOpioidOverdoseDeaths-UnitedStates,2000-2014.AmericanJournalofTransplanta%on,16(4),1323–1327.hgps://doi.org/10.1111/ajt.13776Wig,C.E.,Rudd,K.E.,Bhatraju,P.,Rivara,F.P.,Hawes,S.E.,&Weiss,N.S.(2017).Neonatalabs,nencesyndromeandearlychildhoodmorbidityandmortalityinWashingtonstate:aretrospec,vecohortstudy.JournalofPerinatology.hgps://doi.org/10.1038/jp.2017.106

neonatal abs,nence syndrome - omed 2017 · neonatal abs,nence syndrome how we got here and where we...

Documents