1. Doing the right things for the right reason

2. NAS Prevention and Opiate Impact on Newborns
Ann Negri, MD, FAPA, DFAPA
Current statistics show that an increasing number of reproductive-aged women in Arizona are using substances, including alcohol, street drugs and prescription pain medication, with limited knowledge of the long-term health consequences. Most alarming is the number of women who continue to use substances during pregnancy. Perinatal exposure to opiates and alcohol place infants at risk for medical, cognitive and developmental complications associated with Neonatal Abstinence Syndrome (NAS) and Fetal Alcohol Spectrum Disorders (FASD).
2013, a total of 4% of all NICU hospital days nationwide were attributed to the care of infants with the neonatal abstinence syndrome, representing an increase of 6 to 7 times from 2004.
In this large study, 23 of 213 centers reported that more than 10% of their NICU days were attributable to these infants in 2013, as compared with 1 of 157 centers in 2004.
Proprietary and Confidential

3. 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
Selective serotonin reuptake inhibitors (SSRIs), including Prozac, Paxil, Zoloft, Celexa, etc.
Methadone
Oxycodone (OxyContin, Percocet)
Benzodiazepines (sleeping pills)
Codeine, Hydrocodone (Vicodin)
Synthetic opioids (Dilaudid, Sublimaze)
Suboxone
Fentanyl
Ativan (Lorazepam)
Illicit drugs
Xanax (Alprazolam)
Heroin
Antidepressants 

4. Neonatal Abstinence Syndrome (NAS)
There were 1,903 cases of NAS from 2008 to 2014

5. 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 :
Newborns exposed to cocaine decreased by 39%
Newborns with Fetal Alcohol Syndrome increased by 67%
Source: Arizona Department of Health Services, July 2015

6. Neonatal abstinence and newborn drug exposure rates per 1,000 births
Narcotic exposure 218% Increase
NAS births
245% Increase
Source: Arizona Health Care Cost Containment System

7. Concentration of NAS births in the Valley

8. Heroin and other substances

9. 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

10. 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.
Symptoms of NAS 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.
Type of drug, how much and for how long the mother used of the drug
How the mothers body breaks down and clears the drug
Whether the baby was born full-term or early (premature)

11. 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, 11

12. 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
In infants exposed to methadone, symptoms of withdrawal may begin at anytime in the first 2 weeks of life, but usually appear within 72 hours of birth and may last several days to weeks
Infants exposed to buprenorphine who develop neonatal abstinence syndrome generally develop symptoms within 12–48 hours of birth that peak at 72–96 hours and resolve by 7 days

13. Symptoms of NAS Blotchy skin coloring (mottling) Irritability
Sleep problems
Diarrhea
Slow weight gain
Excessive or high-pitched crying
Stuffy nose, sneezing
Sweating
Excessive sucking
Trembling and tremors
Fever
Vomiting
Hyperactive reflexes
Increased muscle tone

14. 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
Infant Mental Health and long term effects
Neonatal abstinence syndrome treatment can last from 1 week to 6 months. Even after medical treatment for NAS is over and babies leave the hospital, they may need extra "TLC" for weeks or months.
Although the problems associated with motor development, such as increased muscle tone and persistence of reflexes, usually diminish during the first year, irritability, sleep and feeding problems, and difficulty with calming may continue into the second year for some infants
Language or behavioral problems of varying severity. These included delayed language development, lack of tolerance for frustration, distractibility, and difficulty organizing their behavior.
Cognitive delays, cognitive impairments, including poor spatial recognition, poor memory recall, hyperactivity, and lower IQs
Behavioral issues and developmental delay such as cerebral palsy, seizure disorder, and mental retardation
Attachment relationships impact social and emotional development long term.
Difficulty holding jobs
Difficulty maintaining relationships
Increased risk of drug abuse

16. 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.

17. 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

18. 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. 

19. First Connections: A Mercy Maricopa-sponsored infant mental health program
Pilot with Southwest Human Development started
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

20. 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

21. 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

22. Behavioral health and addiction services
Provider collaboration for treating pregnant women using substances/opioids
Behavioral health and addiction services
Neonatologists,
pediatricians OB
Medical
specialists
MEMBER
Pain managements specialists
Parent/infant monitoring
from 0-5

23. 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

24. Supporting a standardized approach to NAS diagnosis

25. Keys to reducing NAS CONSIDER substance issues with all pregnant women
DISCUSS substance issues with all pregnant women
COORDINATE substance issues with all providers
CONSIDER substance issues with all pregnant women
With the increased use of prescription controlled substance medications, it is importance to consider all substance use with all pregnant members.
DISCUSS substance issues with all pregnant women
Because so many people do not view prescription medications as a “substance,” it is important to engage in a face-to-face discussion about all types of substance use with all pregnant members, even when the woman does not report or denies use. Review the Controlled Substance Prescription Monitoring Program (CSPMP) for all pregnant members:
COORDINATE substance issues with all providers
Because members are medically complex and often have more than one provider, coordination of care is necessary between behavioral health, pain management, PCP other specialists, and Mercy Maricopa’s Integrated Care Intensive Clinical Care Manager, to promote positive outcomes.

26. 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; Available at: Retrieved February 9, 2012.

27. 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

28. Considerations for treatments, testing
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

29. Benefits of Medication Assisted Treatment
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)

30. 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 co-management.

31. 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

32. 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.

33. 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.

34. 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.

35. 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
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.

36. 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 or call
Source: Arizona Revised Statute §

37. 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 or SOS-CHILD, or online at

38. Provider best practices
Use Arizona Opioid Prescribing Guidelines
Take the new online course for Arizona DEA prescribers developed by the University of Arizona
Talk to women of childbearing age about NAS

39. Resources and references
Clinical Report: Neonatal drug withdrawal, American Academy of Pediatrics
Neonatal Abstinence Syndrome: How states Can Help Advance the Knowledge Base for Primary Prevention and Best Practices of Care
Arizona Opioid Prescribing Guidelines (November 2014)
March of Dimes NAS information
Controlled Substance Prescription Monitoring Program (CSPMP) syndrome-(nas).aspx
Mother To Baby Arizona

40. Questions?
Thank you