Answering the Questions of Substance Exposure Introduce self Read Consent statement Pass out consents Pass out pre tests Wait for completion WV Perinatal Partnership Initiative of first lady Goal to improve health, environment, family situations and future of children in West Virginia Sandra Young, DNP, RNC

Healthy People 2010- Substance Exposure Abstinence from Smoking During Pregnancy 99% Smoking Cessation During Pregnancy 30% Abstinence from Alcohol Use During Pregnancy 94% Goal to have 100% abstinence of illicit substance use during pregnancy 2010 goals were established in the late 90s early 2000s by Office of Disease Prevention and Health Promotion the US Dept of Health and Human Services The 2020 goals are currently being discussed and established.

How bad is it? State statistics 4.0 % of women pregnant and not pregnant (2006 MOD) (below national average 8.0 – 8.2%) 114,000 used drugs in 2007 (National Survey on Drug Use and Health) 21000 babies x 4.0 = 840 babies born substance exposed 2010 18124 The number of neonates treated for substance abuse tripled from 2003 to 2007, and was seven times greater in 2006 than 1999 816 mothers admitted to substance use from July 2007 to June 2008, 1501 mothers in 2010 103 babies required NICU level 3 care $41,815 average cost 16 day average LOS Average cost of NICU care $1000/day In 2007, 19.9 million Americans were illicit drug users of people 12 years of age and up. 8.0 % of the total population Marijuana was the most commonly used substance, 6.0 % Pregnant women 2007 5.2 % used illicit drugs, 9.7 % of non pregnant Pregnant teens have higher illicit drug use (22.6%) than those not pregnant (13.3%). Women are more often poly-substance users. Women with private insurance have a high use of substances during pregnancy, but most programs target Medicaid

What is the Cost? Baxter, Nerhood, and Chaffin (2008) Forty-eight infants were diagnosed with NAS, with 40 (83.3%) requiring intensive care total hospital costs $1.7 million average cost of $36,700 Medicaid paid 42% of cost in states 3 NICUs

Who paid?

A Blueprint to Improve West Virginia Perinatal Health Policy Recommendations to Improve Perinatal Health 1. Create a Coordinated Statewide Perinatal System 2. Save State Dollars by Reducing Costly Medical Procedures 3. Reduce Exposure to Tobacco Smoke During Pregnancy 4. Reduce Drug and Alcohol Use Among Pregnant Women 5. Improve Breastfeeding Support and Promotion 6. Improve Perinatal Health and Birth Outcomes of African American Women 7. Recruit and Retain More Obstetric Providers 8. Expand Newborn Screening to 29 Conditions 9. Encourage West Virginia Businesses to Offer Perinatal Worksite Wellness 10. Improve the Oral Health of Pregnant Women Through Policy and Education WV Perinatal Partnership Initiative of first lady Goal to improve health, environment, family situations and future of children in West Virginia 2006 Blueprint to Improve WV Perinatal Health conducted a survey of providers in WV.

Why is it a problem? “Overwhelmed: WV Babies being turned away from intensive care” (Charleston Gazette, Nov. 2007) Shortage of NICU Beds Higher number of high risk infants delivered in rural hospitals Increase in number of newborns requiring detoxification due to mother using drugs during pregnancy

What do we do? Caring for drug exposed infants can be emotionally, physically, and mentally demanding upon the nurse. Education may provide an understanding of the consequences of substance abuse on the newly born (Raeside, 2003)

What do we do? “Increased awareness of this growing problem is needed so that earlier interventions can be implemented” (Baxter, Nerhood, and Chaffin, 2008, p1).

When can substance use be identified? Prenatal Postpartum

Prenatal Screening Prenatal Initiative PRISI http://www.wvperinatal.org/downloads/committee_reports_07/Medical_Guidelines_2008.pdf PRISI http://www.wvdhhr.org/rfts/forms/R300_PRSIform_2.pdf WV Healthy Start/HAPI project Helping Appalachian Parents and Infants In May 2009, Governor Joe Manchin signs the West Virginia Maternal Screening Act into law. This law establishes an advisory council on maternal risk assessment within the Office of Maternal, Child and Family Health. The Department of Health and Human Resources will have rule-making authority to develop a uniform maternal risk screening tool to serve as an alert to medical care providers of the need for greater evaluation and assessment of high-risk pregnancies The 4P’s9 is a four-question screen specifically designed to quickly identify obstetrical patients at risk for alcohol or illicit drug use. Parents Did either of your parents ever have a problem with alcohol or drugs Partner Does your partner have a problem with alcohol or drugs Past – have you ever drunk beer, wine, or liquor? Pregnancy – In the month before you knew you were pregnant, how many cigarettes did you smoke? In the month before you knew you were pregnant, how much beer, wine, liquor did you drink Helps identify those with potential problems and promote early intervention. A study published in April 2009, by Hicks, et al. surveyed new mothers in Canada, 1509 participated. 93.8 % said they would consent to screening of their newborn and 97.6 % said they thought all mothers should consent if infants at risk would be more likely to receive effective treatment. Wanted to know: What would happen if infant was Positive., who would have access to the information, How effective medical care would be, and likelihood a positive baby would have a problem (Education!!)

When should you be more alert Mother No prenatal care Late prenatal care Limited prenatal care Unanticipated delivery outside the birthing facility Drop in delivery (Hospital/doctor hopping) Abruptio placenta Maternal admission to drug use during pregnancy Positive Maternal drug screen  

When should you be more alert Infant Unexplainable premature delivery Unexplainable small for gestational age Unexplainable small head circumference Unexplained seizures, intracranial bleeds, or strokes Unexplained symptoms that might suggest drug withdrawal: High pitched crying, irritability, hypertonia, lethargy, disorganized sleep, sneezing, hiccoughs, drooling, diarrhea, feeding problems, or respiratory distress. Unexplained congenital malformations involving genitourinary tract, abdominal wall or gastrointestinal systems

How is substance use identified Meconium Urine Cord Blood Hair Umbilical Cord Urine specific gravity impacts findings of drug screens. Infant concentrations are lower due to fluid loss at birth Cord blood Hair Umbilical Cord – talk briefly about study

What did the leaders say? How do you identify drugs of abuse in pregnant women? Personal Report 76.2% Blood Test 28.6% Urine Test 76.2% Other 4.8% Prenatal Record

What did OB leaders say about substance use in WV? What do you perceive to be the most common drug exposure in your neonate population? Methamphetamine 15% Cocaine 30% Marijuana 85% Opiates 35% Poly substance abuse 5% Other 30% Methadone Cigarettes Barbiturates in addition to those mentioned Benzos

What substances are most frequently used? From July 2007 to June 2008 816 or 5% reported drug or alcohol use during pregnancy. 489 (59%) reported using marijuana, 143 methadone 110 cocaine 29 methamphetamine 22 heroin Alcohol use during pregnancy was reported by 185 mothers. Poly-substance use was also identified, with 117 mothers admitting to poly-substance use (Tolliver, 2008).

2010 172 alcohol <1% 75 cocaine <1% 669 marijuana 3.6% 231 methadone 1.3% 30 heroin <1% 50 methamphetamine <1% 446 other opioids 2.4% 1501 drugs 8.3% Total 9.2%

What are the effects of these substances? Marijuana Cocaine Methamphetamine Opiates, Methadone, Heroin

Marijuana Most commonly used substance after tobacco CNS depressant crosses the placenta and can cause reduction in the heart rate of the fetus urine the first day of life and up to 3 days after delivery in meconium

Marijuana and Delivery Issues Late prenatal care (Burns, et al., 2006) More often required NICU admission

Marijuana Alters neurobehavioral performance (Carvalho do Moraes Barros, et al., 2006) Lower gestational age at delivery Increased risk of prematurity (Sherwood, et al., 1999) Reduction in the heart rate of the fetus (Schaefer, Peters, and Miller, 2007). Growth Reduction

Marijuana Possible post-natal symptoms Irritability Tremors Sleep disturbances Jitteriness

Marijuana Long term outcomes increased risk of childhood leukemia and eye problems, as well as a link to developmental delays (D’Apolito, 1998). increased risk of neuroblastoma in children when mothers use illicit or recreational drugs, particularly when marijuana is used in the first trimester of pregnancy. Bluhm, et al., (2006) First trimester exposure to marijuana affected child’s depression and anxiety symptoms. Second trimester affected reading comprehension and underachievement. Goldschmidt, et al., 2004 Speech and thought impairments

Marijuana and Breastfeeding Passes into breast milk Half life up to 57 hours Exposure to marijuana in breast milk has been linked to delayed motor development Breastfeeding with marijuana use should be discouraged

Cocaine Most widely studied substance of abuse in pregnancy CNS Stimulant Causes vasoconstriction Fetal, uterine and maternal Resulting in infarcts and hemorrhages Placenta appears to block some cocaine absorption Cocaine can be present in neonatal urine for 1-2 days and meconium for up to 3 days following maternal ingestion

Cocaine and Delivery Issues Placental abruption (Ananth, et al., 2006) Premature ROM (Addis, et al., 2001) Pre term labor Less/late prenatal care (Fajemirokin-Odudeyi, et al., 2004) Premature Delivery/prematurity High risk of maternal death from intracerebral hemorrhage Stillbirth High risk of perinatal HIV Higher risk of syphilis

Cocaine Impact on the neonate Delayed auditory brainstem response Low birth weight (Bateman, et al., 1993) Lower length Lower head circumference (Bauer, et al., 2005) IUGR Abnormal fetal monitoring and circulatory issues Higher heart rates (Schuetze and Eiden, (2006) Higher incidence of hypertension (Shankaran, et al., 2006)

Cocaine Meconium staining Malformations Urogenital Brain Midline deformities Skull defects, encephaloceles Ocular malformations Vascular disruptions, such as limb reduction and intestinal atresia Cardiac

Cocaine Neurodevelopmental Hypertonia Tremors Strokes Seizures Brainstem conduction relays

Cocaine Possible Post-natal Effects Tremors and jitters (Bauer, et al., 2005) High pitched cry Excessive sucking Possible Seizures Tachycardia Tachypnea Apnea Hyperirritability (may occur as late as 30 days after birth)

Cocaine Long term issues Higher infection rates Negative behavioral outcomes at 3, 5 and 7 year follow-up (Bada, et al., 2007) Lower IQ scores Higher risk of SIDS

Cocaine and Breastfeeding Appears in breast milk within 15 minutes of absorption Half life less than ½ hour Clears from breast milk within 5 hours A cocaine-using, breastfeeding mother should pump and discard breast milk for 24 hours after cocaine use. Ideally abstaining from cocaine would be the first choice. Habitual cocaine users should avoid breastfeeding

Methamphetamine Least studied substance of abuse CNS Stimulant Causes vasoconstriction Placenta Fetal organs more likely to have APGAR scores of <7 (Ludlow, et al., 2004). likely to be small for gestational age (SGA). Administration of Narcan to a methamphetamine exposed neonate could result in the seizure activity.

Methamphetamine and Delivery Issues Higher incidence of stillbirth Poor prenatal care Sexually transmitted diseases Placental Abruption Postpartum hemorrhage

Methamphetamine Signs of exposure hyperexcitability, disturbances in muscle tone, Cardiac Defects “Transposition of great vessels” Cleft Lip Biliary Atresia

Methamphetamine Possible Post-natal Symptoms Tremors and jitters (Bauer, et al., 2005) High pitched cry Excessive sucking Possible Seizures Tachycardia Tachypnea Apnea Hyperirritability (may occur as late as 30 days after birth)

Methamphetamine Long term outcomes Mothers have lower quality of life perceptions Greater likelihood of substance use in family and social system Increased risk for ongoing legal difficulties Increased likelihood of development of a substance abuse disorder (Derauf, et al., 2007) Potential for the following issues: Respiratory Illnesses Ingestion Rashes Burns

Methamphetamine and Breastfeeding Passes into breast milk Half life unknown Breastfeeding with methamphetamine should be discouraged

Opiates Opiates Morphine Heroin Methadone Demerol/ Meperidine Codeine

Opiates More likely to require resuscitation (Ludlow, et al, 2004) APGAR scores methadone exposed equivalent to those neonates not exposed to opiates More feeding problems (LaGasse, et al., 2002) Higher rates of prematurity, SGA,(Martinez, Partridge, and Taeusch, 2005)

Opiates and Delivery Issues Late prenatal care (Burns, et al., 2006) More often require NICU admission Antepartum hemorrhage Increased risk of HIV (if mother an intravenous heroin user) More likely to require resuscitation (Ludlow, et al, 2004) Higher incidence of placental abruption Higher incidence of premature delivery, preterm labor Higher incidence of chorioamnionitis Higher rates of meconium staining

Opiates Higher incidence of SIDS

Opiates and Breastfeeding All opiates pass into breast milk Heroin using mothers should not breast feed Methadone appears to be well tolerated in breast milk as there appears to be minimal transfer into breast milk Breastfed babies of methadone using mothers have less symptoms of withdrawal and the need for medication treatment (AAP and Jansson, et al, 2008)

Neonatal Abstinence Syndrome (NAS) Lifshitz, et al., (2001) found that 96% of neonates exposed in-utero to narcotics exhibited NAS. Symptoms appear on average at 72 hours May not appear for a long as 4 weeks

Symptoms of Neonatal Abstinence Syndrome Central Nervous System Dysfunction Irritability Excessive Crying Jitteriness Tremulousness Hyperactive reflexes Increased tone Sleep disturbance Seizures

Neonatal Abstinence Syndrome Autonomic Dysfunction Excessive sweating Mottling Hyperthermia Hypertension Respiratory Symptoms Tachypnea (rapid breathing) Nasal stuffiness

Neonatal Abstinence Syndrome Gastrointestinal and feeding disturbances Diarrhea Excessive Sucking Hyperphagia (eating too much)

How do we determine withdrawal Do you use an abstinence/withdrawal scoring tool on your neonates? NO 57.1% Yes 23.7% Neonatal Abstinence Scale 14.3% Finnegan 14.3% Modified scale 9.5% Other 14.3% CAMC Johns Hopkins/Bayview Use risk assessment to determine who needs tested

Assessment Tools http://www.rch.org.au/nets/handbook/media/NASS_1.pdf

What do you use to treat for withdrawal in neonates Methadone 50% Paregoric 6.2% Other 50% No protocol at this time None Morphine Transport out if symptoms Transferred to tertiary center for treatment if needed Haven’t had an infant that physicians felt needed medication

Treatment Options Where are treatment facilities? Lack of beds where mothers and babies can go together Impact of Methadone clinics Infant Treatment Options Methadone Morphine Phenobarbital

Treatment Options Infant Opioids are most common treatment method Morphine (Jackson, Ting, Mckay, Galea, and Skeoch (2004) opioids most effective Sarkar and Donn (2006) Opioids - opioid and poly-substance use Methadone – opioid use Phenobarbital – poly-substance use

What Can We Do to Help? Rooming in Discharge Planning Early Intervention At home Community Services Birth to Three 1-866-321-4728 Right from the Start CSHCN Ski*Hi

Do I have to call? Keeping Children and Families Safe Act mandates the reporting by healthcare providers to child protective services any infant born and identified as being affected by illegal substance abuse and withdrawal symptoms Call the county DHHR office or Child Abuse and Neglect Hotline (1-800-352-6513)   7 days a week, 24 hours a day  

Where can I find help? www.samhsa.gov

Questions Thank you! Post test Attitude survey evaluations.