Answering the Questions of
Substance Exposure
Sandra Young, DNP, RNC
Healthy People 2010Substance 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
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
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?
Methods of Payment of Substance Using Mothers
3% 1%
10%
3%
OTHER
INSURANCE
SELFPAY
MEDICAID
UNKNOWN
83%
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
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
– http://www.wvperinatal.org/downloads/committee_reports_07/Me
dical_Guidelines_2008.pdf
• PRISI
– http://www.wvdhhr.org/rfts/forms/R300_PRSIform_2.pdf
• WV Healthy Start/HAPI project
• Helping Appalachian Parents and Infants
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
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
• Yes
–
–
–
–
57.1%
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!