1. Neonatal Abstinence Syndrome: Taking Care of Mom and Baby Heather Rodman, PharmD PGY-2 Pediatric Pharmacy Resident Peyton Manning Children’s Hospital St. Vincent Hospital and Health Services September 2014 This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.

2. Definition Withdrawal after prenatal exposure to certain drugs Dysregulation of the central, autonomic, and gastrointestinal functioning of the neonate 2 Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560. Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334. Logan BA, et al. Clin Obstet Gynecol. March 2013; 56(1): 186-192. Drug Estimated Onset of Signs/ Symptoms Opioids24-72 hours, up to 7 days pending half-life Benzodiazepineshours – weeks Alcohol3-12 hours

3. Signs / Symptoms 3 Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560. Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334. Logan BA, et al. Clin Obstet Gynecol. March 2013; 56(1): 186-192.

4. TAKING CARE OF MOM 4

5. Prenatal Care Enrollment in an opioid maintenance program Minimizes cravings and optimizes maternal health Prevents fetal stress and suppresses withdrawal Anticipatory neonatal withdrawal Methadone is most commonly chosen Buprenorphine may shorten treatment duration and hospital stay of the neonate Increased dropout rate with buprenorphine Increased doses may be required during 3 rd trimester 5 Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560. Logan BA, et al. Clin Obstet Gynecol. March 2013; 56(1): 186-192. Jones HE, et al. NEJM. Dec 2010; 363(24): 2320-2331.

6. Addiction Resources Indiana Addictions Issues Coalition (IAIC) http://recoveryindiana.org/index.php United States Recovery List of support groups and treatment centers by state http://www.usrecovery.info/index.htm National Institute on Drug Abuse (NIH) Resources for professionals, patients, and families http://www.drugabuse.gov/ National Council on Alcoholism and Drug Dependence http://ncadd.org/index.php American Congress of Obstetricians and Gynecologists (ACOG) http://www.acog.org/Patients/FAQs/Tobacco-Alcohol-Drugs-and-Pregnancy 6

7. TAKING CARE OF THE NEONATE 7

8. Non-Pharmacologic Measures Dark, quiet environment Swaddling and comforting techniques Swaying, rocking Skin-to-skin contact (parents only) Music therapy Small but frequent feedings Breast feeding approved by AAP Contraindications: HIV (+) Relative contraindications: Hepatitis C (+), heroin, cocaine, alcohol abuse Family education 8 Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560. Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.

9. 9 Pharmacologic Treatment Options Langenfeld S, et al. Drug Alcohol Depend. 2005; 77(1): 31-36. Agthe AG, et al. Pediatrics. May 2009; 123(5): e849-e856. Kraft WK, et al. Pediatr Clin N Am. 2012; 59: 1147-1165. Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560. Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.

10. 10 Langenfeld S, et al. Drug Alcohol Depend. 2005; 77(1): 31-36. Agthe AG, et al. Pediatrics. May 2009; 123(5): e849-e856. Kraft WK, et al. Pediatr Clin N Am. 2012; 59: 1147-1165. Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560. Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.

11. Long-Term Outcomes Difficult to evaluate Confounding variables Withdrawal seizures respond to opiates and do not necessarily carry an increased risk of poor outcomes Neurocognitive delays possible during infancy Working memory updating - Resolved at ~ 7 months Regulation and quality of movement Excitability Delay in milestones: Independent sitting, crawling 11 Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560. Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334. Logan BA, et al. Clin Obstet Gynecol. March 2013; 56(1): 186-192.

12. Take Home Points Pregnant women on methadone may require higher doses during pregnancy Buprenorphine is now considered a safe, alternative option for pregnant women enrolled in an opioid maintenance program Breastfeeding is beneficial for NAS even while the mom is still enrolled in the maintenance program 12

13. Assessment Question During which trimester is a pregnant woman most likely to require her highest dose of methadone? A.1 st Trimester B.2 nd Trimester C.3 rd Trimester 13

14. QUESTIONS? 14

15. Thank You 15 Heather Rodman, PharmD PGY-2 Pediatric Pharmacy Resident Peyton Manning Children’s Hospital St. Vincent Hospital and Health Services September 2014