NEONATAL ABSTINENCE SYNDROME Assessment, Identification and Treatment Kate Colvin RNC-OB, C-EFM, LCCE, BSN

OPIUM: “THE PLANT OF JOY” Known for euphoric effects for over 6000 years Used in Ancient Egypt for religious rituals, painless death, and to calm children Medical uses: treating pain (headache, cramps) respiratory issues (asthma, cough) infections (fever, leprosy) mental problems (melancholy) As opium use spread throughout Europe and China, so did it’s abuse and addiction

MORE POTENT IS LESS ADDICTIVE? Theory: if potency is increased, less drug is needed, resulting in less addiction Morphine was isolated from opium in 1803 Has 10x the euphoric effect of opium Used as a treatment for opium addiction, pain relief, and alcoholism Proved to be just as addictive as opium, so the search continued for an opium derivative that would not cause addiction

HEROIN 1898: derivative of morphine developed at Bayer lab in Germany 2-5x more potent than morphine Named heroin, from the German heroisch, meaning heroic, strong Marketed in the early 1900s as an over-the-counter treatment for colds, sore throats, pneumonia, and tuberculosis Believed to be safe for pregnant women and infants Proposed as a treatment for morphine addiction

MORE POTENT IS NOT LESS ADDICTIVE Early 1900s: Opiate addiction skyrocketed Public perception: opiate addiction was better than alcoholism Poor governmental regulation of the sale and distribution of narcotics 300,000 addicts, with 2/3 being women

METHADONE AND BUPRENORPHINE 1946: Synthesis of methadone for use as a maintenance med for opiate addiction programs, including treatment of pregnant opiate addicts Late 1950’s: Term “opioid” refers to synthetic narcotics 1966: Buprenorphine discovered, less addictive than methadone 1985: Buprenorphine approved by the FDA, but only approved for use in opioid treatment programs until 2000 (Drug Addiction Treatment Act)

OPIOID ADDICTION Mid to late 1980s: Opioid treatment for chronic pain becomes popular based on the (incorrect) assumption that chronic opioid use would not lead to addiction 2012: 259 million Rx for opioid meds in the U.S. 2014: 19,000 deaths from opioid overdose Stricter guidelines for opioid Rx has led to an increase in heroin use (often easier to find) 2015: 2 million people living with substance abuse disorder r/t Rx opioids in the U.S. 591,000 people living with heroin abuse disorder 13,000 died from heroin overdose (5x the number in 2002)

OPIOID USE DURING PREGNANCY 1995-2009: opioid Rx for pregnant women doubled Pregnant women addicted to opioids may not seek treatment for fear of legal issues Stopping opioids in pregnancy is not advised- can lead to poor neonatal outcomes Methadone and buprenorphine seem to be safe for treating pregnant women with opioid addiction

CONGENITAL MORPHINISM Perceptions prior to 1875: Women who used morphine were sterile and/or had a loss of sexual desire Infants born to opioid dependent mothers were not affected 1875: Infants born to morphine-dependent mothers were noted to be dying Called “Congenital Morphinism” Full-term infants that appeared normal at birth, but started crying inconsolably 3 days later (some developing seizures) Lack of treatment due to lack of knowledge about the meaning of these symptoms 1901: Breastfeeding infants with CM and/or giving small amounts of meds could ease symptoms Between late 1800s and mid 1900s, mortality rate for untreated infants with CM was >90%

WHAT IS NAS? Neonatal Abstinence Syndrome (NAS) is the medical term for infants experiencing withdrawal as a result of the abrupt cessation of passive transfer of maternal opioids used during pregnancy Opioid drugs could be Rx pain meds, Rx maintenance meds for opiate addictions, or illicit street drugs Important to remember that infants are not “addicted” to drugs Infants are passively exposed to drugs in utero After birth, infants experience withdrawal, but do not seek drugs or have uncontrollable cravings

INCIDENCE Premature infants may have fewer NAS symptoms because their CNS is immature, they have lower body fat, and have lower total exposure than full-term babies 2000-2009: NAS increased from 1.2 to 3.4 per 1000 births Total hospital charges increased from $190 million to $720 million 2009: 13,500 babies treated for NAS, representing approx. 1 baby per hour Average length of stay is 2 days for non-NAS infant and 13-23 days for NAS infant

SIGNS AND SYMPTOMS Neurologic Gastrointestinal Metabolic/Vasomotor Respiratory Excessive and/or high pitched cry Disturbed sleep pattern Hyperactive Moro) reflex Tremors and/or seizures Increased muscle tone Excoriation (except in diaper area) Excessive sucking Poor feeding Uncoordinated sucking/swallowing Regurgitation Projectile vomiting Loose and/or watery stools Sweating Fever Mottling Nasal stuffiness Sneezing Nasal flaring Tachypnea

FINNEGAN NAS TEST (FNAST) Developed in 1975 as an objective and reliable tool to identify infants with NAS Considered to be the gold standard assessment tool Consist of 21 items evaluating the S/S of NAS Scoring begins 2 hours after birth and then every 3-4 hours (usually with feeds) Scores < 8 : non-pharmacologic treatment Scores > 8 for three consecutive periods or >12 for two consecutive periods: pharmacologic treatment may be considered

Video of Dr. Karen D'Apolito demonstrating the assessment of an infant with NAS.

TREATMENT The goal of treatment is to “ensure that the infant receives adequate nutrition and sleep in order to achieve weight gain and integrate into the social environment” – Clark and Rohan, 2015 Small, frequent feedings to minimize GI upset and promote weight gain Non-pharmacologic: comfort measures, swaddling, decreased environmental stimuli, pacifier, gentle rocking, massage Medications: morphine, methadone, buprenorphine, phenobarbital Teach parents about the S/S of NAS, treatments (both meds and non-pharm), SIDS prevention Mothers on methadone or buprenorphine should be encouraged to breastfeed

DOES TYPE OF DRUG MATTER? Prenatal dosage of methadone does not seem to correlate with NAS development Prenatal use of buprenorphine seems to require shorter treatment time than methadone Heroin: NAS usually develops within 6 hours of birth Methadone/ Buprenorphine: NAS usually develops after 36 hours

NURSING CARE CONSIDERATIONS Comfort measures: swaddle, encourage KC, decrease stimuli, dark/quiet room, infant seat or swing, pacifier Assess and document: VS and NAS scores Sleep/wake cycles Intake (amount and length of feeds) Output (voids and stools) Daily weights Calming methods and response Response to handling Foster a positive relationship with the mother Involve her in infant care Respect her dignity and communicate on a personal level

WHAT DOES NCLEX WANT YOU TO KNOW? ATI book, Chapter 27, pages 183-184 Manifestation of S/S of NAS is related to the amount and type of drug, length of time exposed, maternal and infant drug metabolism, genetic factors Nursing assessments for NAS infants Nursing care of NAS infants Treatments including non-pharm and meds Lab tests to differentiate between NAS and CNS disorders CBC, glucose, electrolytes, thyroid hormones, drug screen in mom Chest X Ray for FAS to rule out congenital heart defects

MORE NCLEX REVIEW Heroin withdrawal: associated with low birth weight, NAS, and increased risk of SIDS Marijuana withdrawal: increased risk for meconium-stained amniotic fluid, preterm birth, deficits in attention, cognition, memory, and motor skills Amphetamine withdrawal: increased risk for preterm birth, SGA, delayed growth/development Tobacco: increased risk for SIDS, bronchitis, pneumonia, developmental delays, prematurity, SGA Fetal Alcohol Syndrome: facial anomalies, deafness, abnormal palmar creases, irregular hair, organ anomalies, delayed growth/development, sleep disturbances

WHAT DOES THIS MEAN FOR WV? 2016: WV had the highest number of opioid deaths in the U.S.: 733 deaths (a rate of 43.4 deaths per 100,000) 2013: WV had the highest incidence of NAS in the U.S.: 33.4 infants per 1000 births (lowest was Hawaii at 0.7 per 1000)

REFERENCES Gomez-Pomar, E., & Finnegan, L. P. (2018). The Epidemic of Neonatal Abstinence Syndrome, Historical References of Its’ Origins, Assessment, and Management. Frontiers in Pediatrics , 6 , 33. Retrieved from https://doi.org/10.3389/fped.2018.00033 Jones, H. E., & Fielder, A. (2015). Neonatal abstinence syndrome: Historical perspective, current focus, future directions. Preventive Medicine , 80 , 12–17. Retrieved from https://doi.org/10.1016/j.ypmed.2015.07.017 Kocherlakota, P. (2014). Neonatal abstinence syndrome. Pediatrics , 134 (2), e547–e561. Retrieved from https://doi.org/10.1542/peds.2013-3524 National Institute on Drug Abuse. (2018, February 28). West Virginia Opioid Summary. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/ opioid-summaries-by-state/west-virginia-opioid-summary Heroin Overview : Origin and History | Methoide. (n.d.). Retrieved from https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=174