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New Neonatal Abstinence Syndrome in NICU Dr. Darshan Shah Asst. Professor of Pediatrics Quillen College of Pediatrics.

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Presentation on theme: "New Neonatal Abstinence Syndrome in NICU Dr. Darshan Shah Asst. Professor of Pediatrics Quillen College of Pediatrics."— Presentation transcript:

1 New Neonatal Abstinence Syndrome in NICU Dr. Darshan Shah Asst. Professor of Pediatrics Quillen College of Pediatrics

2 New Neonatal Abstinence Syndrome in NICU Drug use in general population How Common or Uncommon it is? Prescribed/Illicit/Not intended

3 New Neonatal Abstinence Syndrome in NICU 2010 Data of National Drug Survey: High School Senior : 1 in 3 used medical prescription or OTC drug for Non-Medical reason #### 33%% Pregnant women years 23% Vs 13% Non pregnant

4 New Neonatal Abstinence Syndrome in NICU Why rise in narcotic prescription? What it takes to get prescription? What it makes easy or difficult in pregnancy?

5 New Neonatal Abstinence Syndrome in NICU MMT shifted from FDA to Center of Substance Abuse and Addiction in 2001 Standard for Methadone prescription not well defined and not uniformly followed More philosophy to “treat and better outcome” Rise in number of ‘Pain Clinics” last decade

6 Pain Clinics

7 Pain clinics in TN DC RecoveryMemphisTN(901) Atenley Drug CenterGreenvilleTN(423) DRD Knoxville Medical Clinic KnoxvilleTN(865) DRD Knoxville Medical Clinic CentralKnoxvilleTN(865) Jackson Professional AssociatesJacksonTN(731) Memphis Treatment Center for Research and Addiction Treatment MemphisTN(901) Middle Tennessee Treatment CenterNashvilleTN(615) x104 Midsouth Treatment CenterDyersburgTN(731) Raleigh Professional AssociatesMemphisTN(901) Solutions of SavannahSavannahTN(731) x2760 The Mustard SeedNewportTN Volunteer Treatment Center IncChattanoogaTN(423)

8 Pain clinics in NC Western Carolina Treatment CenterAshville NC(828) ADS Alcohol and Drug ServicesBurlingtonNC(336) Alcohol and Drug Abuse Treatment CtrButnerNC(919) McLeod Addictive Disease CenterCharlotteNC(704) Metro Treatment of North Carolina LP Charlotte Treatment CenterCharlotteNC(704) Mountain Area Recovery Center WestClydeNC(828) BAART Community HealthcareDurhamNC(925) Durham Treatment CenterDurhamNC(919) Carolina Treatment Center (CTC)FayettevilleNC(910) Metro Treatment of North Carolina LP Fayetteville Treatment CenterFayettevilleNC(910) McLeod Addictive Disease CenterGastoniaNC(704) Alcohol and Drug Services ADS EastGreensboroNC(336) Greensboro Metro Treatment CenterGreensboroNC(336) PORT Human Services Methadone/IV ProgramsGreenvilleNC(252) Walter B Jones Alcohol and Drug Abuse Treatment CtrGreenvilleNC(252) McLeod Addictive Disease Center HickoryHickoryNC(828) Alcohol and Drug Services ADS WestHigh PointNC(336) Jacksonville Treatment CenterJacksonvilleNC(910) McLeod Addictive Disease Center MarionMarionNC(828) McLeod Addictive Disease CenterMonroeNC(704) Carolina Treatment Center of PinehurstPinehurstNC(910) Raleigh Methadone Treatment Center (RMTC)RaleighNC(919) Rocky Mount Treatment CenterRocky MountNC(252) Sanford Treatment Center LLCSanfordNC(919) McLeod Addictive Disease Center StatesvilleStatesvilleNC(704) New Hanover Metro Treatment CenterWilmingtonNC(910) Wilmington Treatment CenterWilmingtonNC(800) Insight Human Services Winston SalemNC(336)

9 Pain Clinic What it takes to get prescription for pain? History of Heroine/IV drug use/Morphine History of illicit Hydrocodone/Percocet/other drugs History of chronic pain(?) not relieved by other medicine History of anxiety/nervousness

10 Reason to Use Methadone According to NID Methadone is used to relieve moderate to severe pain that has not been relieved by non-narcotic pain relievers. It also is used to prevent withdrawal symptoms in patients who were addicted to opiate drugs and are enrolled in treatment programs in order to stop taking or continue not taking the drugs. Methadone is in a class of medications called opiate (narcotic) analgesics. Methadone works to treat pain by changing the way the brain and nervous system respond to pain. It also works as a substitute for opiate drugs of abuse by producing similar effects and preventing withdrawal symptoms in people who have stopped using these drugs.

11 Pain Clinics What all these medications use has done?

12 Effects of Illcit/prescribed/Abused medication

13 Effects on Mortality

14 Incidence Across States

15 Data Regarding Maternal Drug Use 2000: 1.7/ :2.2/ : 3.1/ : 5.7/1000

16 NAS rate 2000: : : : 2.9

17 Maternal drug use and NAS

18 Newborn Vs NAS baby

19 Maternal Medication Which is better? ◦Methadone ◦Subutex (Bupronorphine) ◦Suboxone (Bupronorphine and Naloxone)

20 Maternal Medication Methadone: Only recommended treatment for pregnant women till recently (2007-8) Longest experience in pregnancy Full mu-opioid agonist Dose: 40 mg to 120 mg Minimum possible dose

21 Maternal Medication Methadone: Earlier studies shown treatment with methadone better than “street drug; no treatment or detox” during pregnancy regarding preterm birth, infectious complication, neonatal death and maternal morbidity. So it became “standard of care” for IVD and other illicit opioid drug

22 Maternal Medication Problems after Methadone: Higher incidence of NAS It depends on dose, duration and other concomitant drugs Umbilical cord level of EDDP (Ethylene Dimethyl Diphenylpyrolidine) correlates NAS better than Methadone concentration

23 Maternal Medication Subutex (Buprenorphine) Partial-mu-oipiod agonist and kappa- opioid antagonist ◦Less than maximal opioid effect ◦Diminished risk of overdose ◦Minimal risk from abrupt withdrawal ◦Dose: 4 mg to 30 mg

24 Maternal Medication Trial of Methadone Vs Subutex Drugs and Alcohol: only 20 patients combined It showed Subutex not inferior to Methadone NEJM 2010: 131 Neonates were part of study. Drugs 2012: Meta analysis Results

25 Maternal Medication Buprenorphine exposed newborn required significantly less morphine Shorter duration of treatment Shorter hospital stay So what’s problem?

26 Maternal medication Dissatisfaction rate was 71% in Subutex group versus13% in Methadone group in NEJM trial. Main barrier for use of Subutex

27 Maternal Medication Suboxone ( Buprenorphine and naloxone in 4:1 combination) Combination of partial mu Opioid receptor agonist with opioid antagonist When taken by sublingual route no effect of Naloxone only Buprenorphine like Subutex effect but when injected/Parental route it causes withdrawal in opioid dependent subjects

28 Maternal Medication Doses: 4/1, 8/2 and 16/4 No direct comparison with Methadone but essential same as Subutex when taken as a sublingual tablet

29 Newborn

30 Newborn When born to drug exposed mother what to expect and when to expect? How to diagnose Neonatal Abstinence Syndrome (NAS) or Maternal Medication Withdrawal Syndrome ?

31 NAS NAS: CONSTELLATION OF SIGNS AND SYMPTOMS RESULTING FROM DYSFUNCTION OF Autonomic nervous system Gastrointestinal tract Respiratory system

32 NAS Finnergan Scoring System Most widely used screening method What’s significant score?

33 NAS Treatment: Nonpharmacological Noise/light/distraction free QUITE atmosphere Bundle care Hyper caloric feeding

34 NAS

35 NAS Medication Morphine: 0.1mg/kg q 4 hrs Methadone: 1mgkg q 24 hrs Clonidine: by mouth every 6 hrs Phenobarb: 2-5 mg/kg every 12 hrs

36 NAS Future treatment Ondansetron (Zofran) Immunomodulator Vaccine Genetic

37 NAS



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