1. Neonatal Abstinence Syndrome

2. Risks for developing NAS Opioids – Opiate derivatives, interact with mu-opioid receptor Abstinence syndrome (withdrawal) experienced following variable length of repeated exposure

3. Risks for developing NAS “Narcotics” – Definition Cocaine PCP Stimulants – Amphetamine and derivatives Methamphetamine Amphetamine MDMA Many others

4. Risks for developing NAS Other possible culprits? – SSRI/SNRI – marijuana – Caffeine – Tobacco – Alcohol – Everything else we “should not use”

5. Risks for developing NAS When does it happen – Immediately – 72-96 hours – Weeks – Never

6. Risks for developing NAS Breastfeeding Co-morbidities – HIV – Hep B, Hep C

7. Consequences of NAS Seizures Temperature instability Poor feeding Hypoglycemia Inadequate Sleep

8. Recognizing NAS Neonatal abstinence scales – Most commonly used is Finnegan – Several others avaiable – Positive screen threshold is 8 – Score of 24 on any 2 or 3 scores leads to intervention

9. Finnegan NAS scoring tool (handout) Example cases discussed with audience Practice with examples to determine score Will complete several scorings, discuss ease of use of the tool

10. Therapy for NAS Ideally, replace the substance that is suddenly missing Slowly reduce the exposure over time

11. Therapy for NAS Alternatively substitute another similar substance – Safety – Availablilty – Efficacy for symptom control

12. Therapy for NAS Possible approaches – Replacement Chronic pain syndromes Continue to use original or similar substance Morphine – Substitution Illicit use of schedule I substances Heroin – Use another mu opioid » Methadone » Burpenorphine +/- Naloxone » Morphine

13. Therapy for NAS Possible approaches – Symptom Relief Tylenol Clonidine Phenobarbitol (barbiturate)

14. Therapy for NAS Symptom Relief – Antihistamines – Restraint

15. Therapy for NAS – Substitution (same class) Illicit use of schedule I substances Heroin – Use another mu opioid » Methadone » Burpenorphine +/- Naloxone » Morphine

16. Therapy for NAS – Substitution (different class) Phenobarbitol Clonidine

17. Prevention Methadone – Lower dose? » No change in rate Buprenorphine Naloxone Fentanyl, MS-Contin (morphine) SSRI