Doing the right things for the
right reason
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NAS Prevention and Opiate
Impact on Newborns
Ann Negri, MD, FAPA, DFAPA
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Neonatal Abstinence Syndrome (NAS)
NAS is when a newborn baby has withdrawal signs from certain
prescription medications or street drugs the mother used
during pregnancy. Some of these include:
Prescription medications
• Methadone
• Oxycodone (OxyContin, Percocet)
• Codeine, Hydrocodone (Vicodin)
• Suboxone
• Fentanyl
• Ativan (Lorazepam)
• Xanax (Alprazolam)
• Antidepressants
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• Selective serotonin reuptake
inhibitors (SSRIs), including Prozac,
Paxil, Zoloft, Celexa, etc.
• Benzodiazepines (sleeping pills)
• Synthetic opioids (Dilaudid,
Sublimaze)
Illicit drugs
• Heroin
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Neonatal Abstinence Syndrome (NAS)
500
438
450
400
339
# of NAS cases
350
300
304
2011
2012
300
223
250
200
150
145
154
2008
2009
100
50
0
2010
2013
2014
Source: AZ HDD 2008-2014
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NAS and newborn drug exposures in AZ
From 2008 to 2014:
•
•
•
•
235% increase in the rate of NAS cases
More than 218% increase in newborns exposed to narcotics
White, non-Hispanics made up 68% of the total NAS cases
White, non-Hispanics made up 52% of those narcotic exposure cases, while
Hispanics made up 28% of them
• AHCCCS was the payer in 79% of the overall NAS cases
From 2013-2014:
• Newborns exposed to cocaine decreased by 39%
• Newborns with Fetal Alcohol Syndrome increased by 67%
Source: Arizona Department of Health Services, July 2015
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Neonatal abstinence and newborn drug
exposure rates per 1,000 births
Narcotic exposure
218% Increase
9
8
7
NAS births
245% Increase
6
5
4
3
2
1
0
2008
2009
2010
2011
Neonatal Abstinence Syndrome (779.5)
Narcotic Exposure (760.72)
Fetal Alcohol Syndrome (760.71)
Hallucinogen Exposure (760.73)
2012
2013
2014
Cocaine Exposure (760.75)
Source: Arizona Health Care Cost Containment System
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Concentration of NAS births in the Valley
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Heroin and other substances
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Illicit drug use and associated lifestyle risks
Pregnant women who use illicit drugs aren’t just putting their
baby at risk – they’re also putting themselves at risk. They have
an increase likelihood of getting involved with or facing:
• Prostitution
• Theft
• Violence (becoming victims of violence)
• Sexually transmitted infections
• Loss of child custody
• Criminal proceedings
• Incarceration
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Complications from drug, alcohol use during pregnancy
Possible complications from drug and alcohol use during
pregnancy can lead to many health problems in the baby
besides NAS. These may include:
• Birth defects, smaller head
circumference
• Premature birth
• Sudden Infant Death
Syndrome (SIDS)
• Risk for developmental
problems, such as cerebral
palsy, seizure disorder and
mental retardation.
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Use of opioids during pregnancy
A 2013 analysis revealed that 645 newborns tested positive for
the presence of narcotics. It also found that newborns with
NAS, compared to babies without NAS, were:
•
•
•
•
•
3 times more likely to have a low birth weight
3 times more likely to have respiratory problems
17 times more likely to have seizures
5 times more likely to have feeding difficulties
Staying in the hospital about 13 days vs. a 2-day stay for a
non-NAS newborn
Source: Arizona Statewide Task Force on Preventing Prenatal
Exposure to Alcohol and Other Drugs Strategic Plan, 2015-2010
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Symptoms of NAS
Symptoms often begin within 1 to 3 days after birth, but
may take up to a week to appear. Because of this, the
baby will most often need to stay in the hospital for
observation and monitoring for up to a week.
The type and severity of symptoms depend on various
factors, including:
• The type, amount and duration of drug used
• How mom’s body breaks down and clears the drug
(influenced by genetic factors)
• Whether the baby was born full-term or premature
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Symptoms of NAS
• Blotchy skin coloring
(mottling)
• Diarrhea
• Excessive or high-pitched
crying
• Excessive sucking
• Fever
• Hyperactive reflexes
• Increased muscle tone
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•
•
•
•
•
•
•
Irritability
Sleep problems
Slow weight gain
Stuffy nose, sneezing
Sweating
Trembling and tremors
Vomiting
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Long-term effects of prenatal drug exposure
The effects of NAS can follow a newborn as they get older.
Some of these include:
• Behavioral issues and developmental delays
• Cognitive delays and impairments, including poor spatial
recognition, poor memory recall, hyperactivity and lower IQs
• Increased anxiety
• Difficulty holding jobs
• Difficulty maintaining relationships
• Increased risk of drug abuse
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What happens with at-risk pregnancies
Mercy Maricopa’s data shows that most babies remain with their
mothers. Some pregnancies are terminated. Newborns also end up
in care of family members, adoptive families or the Arizona
Department of Child Safety.
377
112
105
Mother
CPS/DCS
50
17
29
24
Family
Adoption
Terminated
2
Stillbirth
Other
Unknown
Termination = ectopic, fetal demise, miscarriage, abortion
Unknown = recent delivery, no baby disposition yet
Other = mother was out of state or incarcerated during delivery
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Mercy Maricopa’s NAS Program
• Identify pregnant women with substance use/abuse issues
• Educate them about risks/effects of prenatal exposure to
alcohol and other substances
• Provide NAS education, discuss treatment options
• Talk with members addicted to
opioids about a management
plan and how prescribing of
opioids will be handled during
the pregnancy
• Emphasize the continued need
for regular visits to the
obstetrician
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Mercy Maricopa’s NAS Program
•
•
•
•
•
•
Support the mother to remain in substance use treatment –
before and after the baby is born
Begin care management for the infant in the hospital to improve
discharge planning and to start parent/guardian training while
the baby is in the hospital
Identify high-risk and vulnerable parent/child patterns for
mothers with dual diagnoses of serious mental illness (SMI) and
substance use
Screen for depression during and after pregnancy
Refer all pregnant SMI members to Southwest Human
Development for neonatal evaluation and engagement after
delivery
Reduce neonatal intensive care unit (NICU) admissions and
hospital stays from NAS complications.
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First Connections: A Mercy Maricopasponsored infant mental health program
• Pilot with Southwest Human Development started 4-1-2016
• Strong coordination of services between adult and children
systems of care
• Evaluation and support of high-risk and vulnerable parent/child
• Integration, coordination of services for infant mental-health
specialists and adult members with an SMI determination
• Refer all pregnant SMI members to SW Human Development
• Engage with mother prior to delivery
• Continue relationship with mother to coordinate services in the
community
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Southwest Human Development programs
There are several resources and programs available to women
with newborns who have NAS issues. You can share these with
your members/patients. They include:
The Children’s Developmental Center (CDC)
• The Birth to Five Helpline
• The Fussy Baby Program
• The Newborn Intensive Care Program (NICP)
• Nurse-Family Partnership (NFP)
• The Substance Exposed Newborn Safe Environment (SENSE
Program)
• Smooth Way Home Fragile Infant Project
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Care management with Southwest Human
Development
It’s important that all mothers with an SMI
determination and newborn with NAS
issues sign a Release of Information (ROI)
form to allow their SMI providers to
coordinate care after delivery
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Provider collaboration for treating
pregnant women using substances/opioids
Behavioral
health and
addiction
services
Neonatologists,
pediatricians
OB
Medical
specialists
MEMBER
Pain
managements
specialists
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Parent/infant
monitoring
from 0-5
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Infant mental health
Why enroll newborns in behavioral health services?
• Infants and toddlers depend heavily on adults to help them
experience, regulate, and express emotions
• Through close, secure interpersonal relationships with parents
and other caregivers, infants and toddlers learn what people
expect of them and what they can expect of other people
• Attachment relationships impact social and emotional
development long term
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Supporting a standardized
approach to NAS diagnosis
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Keys to reducing NAS
CONSIDER
substance issues
with all pregnant
women
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DISCUSS
substance issues
with all pregnant
women
COORDINATE
substance issues
with all providers
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Considerations while providing care to
pregnant women with substance use issues
• Close communication between the obstetrician and
pediatrician is necessary for optimal care management
• All infants born to women who use opioids during
pregnancy should be monitored for NAS and treated, if
necessary
• Treatment is adequate if the infant has rhythmic feeding
and sleep cycles and optimal weight gain
• Babies born to heroin-addicted mothers are often born
addicted to heroin and are at risk for the same potentially
life-threatening withdrawal side effects, if not medically
maintained and tapered at birth.
Center for Substance Abuse Treatment. Medication-assisted treatment for opioid addiction during pregnancy.
In: SAHMSA/CSAT treatment improvement protocols. Rockville (MD): Substance Abuse and Mental Health
Services Administration; 2008. Available at: http://www.ncbi.nlm.nih.gov/books/NBK26113. Retrieved February 9, 2012.
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Considerations while providing care to
pregnant women and women of
reproductive age
•
•
•
Consider possible substance use, including prescription
opioids
Discuss consequences of substance use and prescription
opioid use with all pregnant women and women of
reproductive age and explain the risk of NAS for infants
exposed to opioids during pregnancy
Include information about the patients’ illicit substance use
and prescription opioid use during pregnancy to the health
plan
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Considerations for treatments, testing
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Initiate methadone treatment as soon as possible
Buprenorphine monotherapy is alternative to methadone
Discontinue naltrexone if relapse risk is low
No naloxone unless there’s an overdose
Discuss breastfeeding with methadone and buprenorphine
•
Psychosocial treatment is
recommended
HIV & Hepatitis (B & C) testing and
counseling
With patient consent, urine testing
for opioids and other drugs
•
•
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Benefits of Medication Assisted Treatment
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Reduce morbidity and mortality
Decrease overdose deaths
Reduce transmission of infectious disease
Increase treatment retention
Improve social functioning
Reduce criminal activity
Evidence-based best practice for treating opioid use
disorder (ASAM and WHO)
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Considerations while providing care to pregnant
women and women of reproductive age
•
•
Refer all pregnant health plan members with substance use
concerns to a High Risk Perinatal Care Management program,
which will assist with coordination of care, facilitate
collaboration between the primary provider and other
providers, and provide education, support and resources to
the member.
Coordinate with any other providers who are prescribing
opioid medications during pregnancy such as behavioral
health providers or pain management providers. Utilize
medical release of information forms as appropriate for comanagement.
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ROI: A federal requirement to coordinate
care
Health care providers should maintain frequent
communication between the patient’s obstetric care provider
and the addiction medicine provider to coordinate care.
Remember that the federal confidentiality law (42 CFR Part 2)
applies to addiction treatment providers. You’re required to
have your patients sign an information release form with
specific language regarding substance use before you can share
information with other providers.
Opioid Abuse, Dependence, and Addiction in Pregnancy - American College of Obstetricians and
Gynecologists http://www.acog.org/Resources-And-Publications/CommitteeOpinions/Committee-on-Health-Care-for-Underserved-Women/Opioid-Abuse-Dependence-andAddiction-in-Pregnancy
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Best practices when providing care to
newborns
•
•
•
Implement a Screening Protocol for Neonatal Abstinence
Syndrome (NAS) and ensure all staff and providers are trained
on the protocol.
Consider possible NAS when signs and symptoms of substance
exposure and/or withdrawal are present even if there’s not a
confirmed history of substance use of opioid use in the
mother.
Implement a Scoring and Treatment Protocol for NAS
according to nationally established best practices and ensures
all staff and providers are trained on the protocol.
• http://www.pqcnc.org/documents/nas/nasresourc
es/VCHIP_5NEONATAL_GUIDELINES.pdf
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Best practices when providing care to
newborns
• Encouraging all birthing hospitals to have a written policy on
the criteria for screening and testing women and infants for
substance exposure.
• Working with child protection service (CPS) agencies to review
and train staff on policies for reporting substance-exposed
newborns.
• Staff and provider should be trained in utilizing evidence based
NAS screening and treatment protocols
• Training should include the recognition of NAS signs and
symptoms
• Tracking outcomes for CPS referrals made for NAS.
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Best practices when providing care to
newborns
• Use non-pharmacological treatment for NAS first,
followed by pharmacological treatment when
warranted
• Refer babies with NAS to health plan care
management for assistance with coordination of
care, resources, support and education of
parents/guardian.
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Provider best practices
• CHECK THE CSPMP. Providers should review the Controlled
Substance Prescription Monitoring Program (CSPMP) for all
pregnant women and women of reproductive age at
https://pharmacypmp.az.gov/
• REFER TO PHARMACY RESTRICTION PROGRAM. If you
believe your patient may be overusing or misusing controlled
substances you should make a referral for possible enrollment
into the Health Plan Pharmacy Restriction Program to notify
the patient’s care manager or by calling the patient’s Health
Plan.
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Provider best practices
It’s important to remember that state law requires each
medical practitioner who is licensed under Title 32 and who
possesses a DEA license to register with the CSPMP. Each DEA
license should have an associated registration.
There is no fee for this registration, which includes: MD, DO,
DDS, DMD, DPM, HMD, PA, NP, ND, and OD.
For more information, go to https://pharmacypmp.az.gov/ or
call 602-771-2732.
Source: Arizona Revised Statute § 36-2606
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Provider best practices
Arizona law requires a health care professional who
“reasonably believes” that a newborn infant may be
affected by the presence of alcohol or a drug” to
immediate report the information to the Arizona
Department of Child Safety. For reporting purposes,
“newborn infant” means a newborn infant who is under
30 days of age.
You can report by calling 1-888-767-4245 or 1-888- SOSCHILD, or online at https://dcs.az.gov/report-childabuse-or-neglect
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Provider best practices
• Use Arizona Opioid Prescribing Guidelines
http://www.azdhs.gov/documents/audiences/clinicians/clinica
l-guidelines-recommendations/prescribing-guidelines/azopiod-prescribing-guidelines.pdf
• Take the new online course for Arizona DEA prescribers
developed by the University of Arizona
www.VLH.com/AZPrescribing
• Talk to women of childbearing age about NAS
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Resources and references
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Clinical Report: Neonatal drug withdrawal, American Academy of Pediatrics
http://pediatrics.aappublications.org/content/129/2/e540.full.html
Neonatal Abstinence Syndrome: How states Can Help Advance the Knowledge Base
for Primary Prevention and Best Practices of Care
http://www.astho.org/Prevention/NAS-Neonatal-Abstinence-Report
Arizona Opioid Prescribing Guidelines (November 2014)
www.azdhs.gov/clinicians/clinical-guidelines-recomendations/
March of Dimes NAS information
Controlled Substance Prescription Monitoring Program (CSPMP)
https://pharmacypmp.az.gov/ http://www.marchofdimes.org/baby/neonatalabstinence -syndrome-(nas).aspx
Mother To Baby Arizona
www.MotherToBaby.org
http://www.pqcnc.org/documents/nas/nasresources/VCHIP_5NEONATAL_GUIDELI
NES.pdf
http://pediatrics.aappublications.org/content/134/2/e547
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Questions?
Thank you
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