New Neonatal Abstinence Syndrome in NICU

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

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

3. 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 18-25 years 23% Vs 13% Non pregnant New Neonatal Abstinence Syndromein NICU

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

5. 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 New Neonatal Abstinence Syndromein NICU

6. Pain Clinics

7. DC Recovery Memphis TN (901) 375-1050 • Atenley Drug Center Greenville TN (423) 639-5255 • DRD Knoxville Medical Clinic   Knoxville TN (865) 522-0161 • DRD Knoxville Medical Clinic Central Knoxville TN (865) 522-0661 • Jackson Professional Associates Jackson TN (731) 660-0880 • Memphis Treatment Center for Research and Addiction Treatment Memphis TN (901) 722-9420 • Middle Tennessee Treatment Center Nashville TN (615) 321-2575x104 • Midsouth Treatment Center Dyersburg TN (731) 285-6535 • Raleigh Professional Associates Memphis TN (901) 372-7878 • Solutions of Savannah Savannah TN (731) 925-2767x2760 • The Mustard Seed Newport TN • Volunteer Treatment Center Inc Chattanooga TN (423) 265-3122 Pain clinics in TN

8. Western Carolina Treatment Center Ashville  NC (828) 251-1478 • ADS Alcohol and Drug Services Burlington NC (336) 532-0500 • Alcohol and Drug Abuse Treatment CtrButner NC (919) 575-7928 • McLeod Addictive Disease Center Charlotte NC (704) 332-9001 • Metro Treatment of North Carolina LP Charlotte Treatment Center Charlotte NC (704) 697-0044 • Mountain Area Recovery Center West Clyde NC (828) 454-0560 • BAART Community Healthcare Durham NC (925) 726-1063 • Durham Treatment Center Durham NC (919) 286-1509 • Carolina Treatment Center (CTC) Fayetteville NC (910) 864-8739 • Metro Treatment of North Carolina LP Fayetteville Treatment Center Fayetteville NC (910) 483-0958 • McLeod Addictive Disease Center Gastonia NC (704) 865-1558 • Alcohol and Drug Services ADS East Greensboro NC (336) 333-6860 • Greensboro Metro Treatment Center Greensboro NC (336) 273-9611 • PORT Human Services Methadone/IV Programs Greenville NC (252) 353-5346 • Walter B Jones Alcohol and Drug Abuse Treatment Ctr Greenville NC (252) 830-3426 • McLeod Addictive Disease Center Hickory Hickory NC (828) 464-1172 • Alcohol and Drug Services ADS West High Point NC (336) 882-2125 • Jacksonville Treatment Center Jacksonville NC (910) 347-2205 • McLeod Addictive Disease Center Marion Marion NC (828) 659-3966 • McLeod Addictive Disease Center Monroe NC (704) 332-9001 • Carolina Treatment Center of Pinehurst Pinehurst NC (910) 235-9090 • Raleigh Methadone Treatment Center (RMTC) Raleigh NC (919) 781-5507 • Rocky Mount Treatment Center Rocky Mount NC (252) 972-4357 • Sanford Treatment Center LLC Sanford NC (919) 776-0711 • McLeod Addictive Disease Center Statesville Statesville NC (704) 871-2992 • New Hanover Metro Treatment Center Wilmington NC (910) 251-6644 • Wilmington Treatment Center Wilmington NC (800) 992-3671 • Insight Human Services  Winston Salem NC (336) 725-8389 Pain clinics in NC

9. 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 Pain Clinic

10. 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. Reason to Use MethadoneAccording to NID

11. What all these medications use has done? Pain Clinics

12. Effects of Illcit/prescribed/Abused medication

13. Effects on Mortality

14. Incidence Across States

15. 2000: 1.7/1000 • 2003: 2.2/1000 • 2006: 3.1/1000 • 2009: 5.7/1000 Data Regarding Maternal Drug Use

16. 2000: 1.5 • 2003: 1.9 • 2006: 2.3 • 2009: 2.9 NAS rate

17. Maternal drug use and NAS

18. Newborn Vs NAS baby

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

20. 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 Maternal Medication

21. 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 Maternal Medication

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

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

24. 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 Maternal Medication

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

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

27. 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 Maternal Medication

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

29. Newborn

30. 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 ? Newborn

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

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

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

34. NAS

35. Medication • Morphine: 0.1mg/kg q 4 hrs • Methadone: 1mgkg q 24 hrs • Clonidine: 0.5 -1 by mouth every 6 hrs • Phenobarb: 2-5 mg/kg every 12 hrs NAS

36. Future treatment • Ondansetron (Zofran) • Immunomodulator • Vaccine • Genetic NAS

37. NAS

38. Thank you • GO DAWGS : SEC EAST CHAMPION NAS