Neonatal Drug Withdrawal Neonatal Drug Withdrawal This is a nationwide problem. In Indiana, this is a problem in all counties. The classic drugs of abuse that cause neonatal withdrawal are opioids such as heroin and morphine. Prescription pain medications such as oxycodone (Percocet), hydromorphone (Dilaudid), and propoxyphene (Darvon) are a relatively new issue. Selective serotonin reuptake inhibitors (SSRIs) have become a problem because of their frequent prescription to pregnant women with depression. Stimulant drugs, such as cocaine and amphetamine, cause symptoms in neonates, though probably due to drug effects or injury, as opposed to classic withdrawal syndromes. Neonatal Drug Withdrawal Summary of the Neonatal Drug Withdrawal Clinical Report from the The Committee on Drugs and The Committee on Fetus and Newborn published in Pediatrics 2012;129;e 540. Cost of the Neonatal Abstinence Syndrome Neonatal Drug Withdrawal Pediatrics 2012;129;e 540 Maternal use of certain drugs can cause transient neonatal signs consistent with withdrawal or acute toxicity or sustained signs consistent with a lasting drug effect. Additionally, our use of narcotics and/or benzodiazepines to provide analgesia or sedation for hospitalized infants puts that population at risk for signs of withdrawal. 2009 National Survey on Drug Use and Health Surveyed population 12 years or older. 8.7%, 23.7%, and 27.7%, respectively, reported recent use of illicit drugs, binge or heavy alcohol ingestion and use of tobacco products. 4.5% of pregnant women 15-44 years of age reported recent use of illicit drugs (marijuana, cocaine, hallucinogens, heroin, methamphetamines, and nonmedical use of prescription drugs). Binge or heavy drinking in the first trimester was reported by 11.9% and recent tobacco use by 15.3%. In the 15-17 year old range, the use of illicit drugs and smoking were higher in pregnant women than in those not pregnant. Discharge Data from Agency for Health Care Research and the Florida Department of Health Using ICD-9 code 779.5 for neonatal withdrawal syndrome the number of infants coded at discharge increased from 7653 in 1995 to 11, 937 in 2008. In Florida, the number of newborns discharged with ICD-9 code 779.5 increased from 0.4 to 4.4/1000 live births from 1995 to 2009. Part of this increase, though exactly how much is not known, is thought to be from the more liberal use of prescription opiates in pregnant women to help with pain from a number of etiologies. Neonatal Drug Withdrawal By far, the most common neonatal drug withdrawal comes from intrauterine opioid exposure. The typical clinical findings associated with opioid withdrawal are called the neonatal abstinence syndrome (NAS). Withdrawal signs develop in 55-94% of neonates exposed to opioids in utero. Neonatal withdrawal signs have also been described in infants exposed to benzodiazepines, barbiturates, and alcohol. Cocaine and Other Stimulants A true abstinence syndrome after exposure to CNS stimulants such as cocaine and amphetamine has not been defined. The neurobehavioral abnormalities that occur frequently 2-3 days after birth in neonates with intrauterine exposure include irritability, hyperactivity, tremors, high-pitched cry, and excessive sucking. Since cocaine and its metabolites may be detected in exposed infants for up to 7 days after birth, the signs may relate more to drug effect than withdrawal. Selective Serotonin Reuptake Inhibitors (SSRIs) This class of antidepressant medications became available for widespread use in 1988. They are now the most frequently used drugs to treat depression. Included are such well known names as Prozac (fluoxetine), Zoloft (sertraline, Lexaprol (escitalopram), and Paxil (paroxetine). SSRIs block the reuptake of serotonin into the presynaptic neuron, thereby increasing the concentration of serotonin in the presynaptic cleft available to bind to serotonin receptors on the postsynaptic neuron. SSRIs Third-trimester use of SSRIs can produce neonatal signs that include continuous crying, irritability, jitteriness, shivering, fever, tremors, hypertonia, tachypnea, feeding difficulty, sleep disturbance, hypoglycemia, and seizures. The onset of signs varies from several hours to several days after birth. Signs typically resolve within 1-2 weeks. Again, it is unknown whether this is a withdrawal syndrome or serotonin syndrome (serotonin overload). Clinical course is frequently one of a slow resolution of signs, which may be more consistent with a hyperserotonergic condition rather than withdrawal. Only paroxetine (Paxil) produces a ratio of infant to maternal plasma concentration that is consistently low (<0.1) with breast feeding. Opioids Opioids are a class of natural, endogenous, and synthetic compounds that activate primarily mu-opiod receptors in the CNS to produce supraspinal analgesia. Morphine is a natural opioid and is extracted from the opium poppy. Codeine, heroin, hydromorphone, fentanyl, and methadone are all synthetic opioids. Opioids acutely inhibit the release of noradrenaline at the synaptic terminals. With chronic opioid exposure, tolerance develops and the rate of noradrenaline release increases toward normal. Abrupt cessation of exogenous opioids results in a supranormal release of noradrenaline and produces the autonomic and behavioral signs characteristic of opioid withdrawal. Opioid Abuse in Pregnancy Opioids are small lipophilic compounds that freely cross the placenta and blood-brain barrier. Maternal detoxification is associated with increased risk of fetal distress and fetal loss. Maintenance programs with methadone for pregnant women sustain opioid concentrations in the mother and fetus in ranges that minimize opioid craving, suppress abstinence symptomatology, block heroin-induced euphoria, and prevent fetal stress. Unfortunately, because of its addictive properties, the use of methadone makes detoxification after delivery unlikely and produces a longer course of NAS than with heroin exposure. Buprenorphine Because of the negative aspects of methadone use synthetic opioids have been developed as alternatives. Buprenorphine, a partial mu-receptor agonist, was approved in 2002 by the FDA for the treatment of opioid dependence. Buprenorphine alone (Subutex) or in combination with naloxone (Suboxone) has been used as a first-line treatment of heroin addiction and as a replacement drug for methadone. Neither methadone or buprenorphine is approved by the FDA for use in pregnancy. There is some data that buprenorphine may produce less withdrawal in neonates and that the withdrawal, when it occurs, is shorter. However, the data is not extensive. Conversion from methadone to buprenorphine during pregnancy requires hospitalization for it to be done safely (for the mother and fetus). Opioid Withdrawal Opioid Withdrawal Since the opioid receptors are concentrated in the CNS and GI tract, you get the signs and symptoms seen in the previous chart. Excess environmental stimuli and hunger exacerbate the perceived severity of NAS. Hence, frequent feeds and a quiet room are part of the treatment of withdrawal. Signs of neonatal withdrawal often begin in the first 24 hours after birth with heroin. In methadone, the withdrawal tends to begin between 24 and 72 hours. However, for both opioids, withdrawal has been reported to take up to 5-7 days to develop. Opioid Withdrawal For buprenorphine, withdrawal onset peaks at 40 hours, is at its worst at 70 hours. The different time courses reflect variations in the half-lives of drug elimination. The incidence and severity of NAS are greater in infants exposed to methadone compared with infants exposed to heroin or buprenorphine. However, up to 50% of infants exposed to buprenorphine may withdraw. Daily maternal methadone dose has not been consistently correlated with the incidence or severity of NAS. Maternal methadone metabolism is probably a more important determinant than the actual daily dose. Opioid Withdrawal Preterm infants do not withdraw as frequently or as severely. It is not known whether that is due to the less mature nervous system or being exposed to a lower total dose of narcotic. Screening for Neonatal Withdrawal Maternal history is important – you have to ask early on in the pregnancy, every pregnancy. Dr. James Nocon/IPN have great resources for screening mothers. Two semiobjective scoring systems are available for neonates, the Lipsitz tool and the modified Finnegan’s Neonatal Abstinence Scoring Tool. Currently, the modified Finnegan’s is the most commonly used. The appropriate length of hospitalization for observation in a term infant is variable, and depends on the drug used and the maternal metabolism. For a drug such as methadone with a prolonged half-life, the infant should be observed for 5-7 days. Breast Feeding Breastfeeding has been associated with less severe NAS presents later and less often requires drug intervention. Breast feeding, safety-wise, requires that the mother be in a supervised drug treatment program and that the mother be HIV and Hepatitis C negative. Methadone is excreted into breast milk, but at a low level. Dose range has been estimated at from 0.01 to 0.15 mg/day in the first 30 days of life. If possible, and safe, breast feeding probably does reduce NAS risk. Pharmacologic Therapy of NAS The optimal screening scores for the initiation of pharmacologic therapy by any published abstinence scoring system are unknown. If nonpharmacologic treatment fails, then the drugs of choice are oral morphine or methadone (94% first choice in UK, 83% first choice in US). Paragoric is no longer used because it contains a multiple other opioids as well as camphor, anise oil, alcohol, and benzoic acid. Tincture of opium contains a 25 fold higher concentration of morphine than currently available oral morphine preparations making accidental overdose a concern. When a second drug is needed, phenobarbital is most commonly picked. Long Term Outcome The long term neurodevelopmental outcome of infants who withdraw is really not known. It is very difficult to tease out the drug effects from the family/social issues. In most cases, what data there is, tends to be reassuring. Whether it is looking at infants who seize secondary to opioid withdrawal or drug toxicity from cocaine, most of the infants appear to do OK over time. That is probably related to the fact that neurotransmitter levels recover over time. Aquired Opioid and/or Benzodiazepine Dependency This section is a new addition. Discusses the drug dependency generated in sick neonates from the use of opioids and benzodiazepines. ECMO patients are heavily represented in this patient population. Most of the data comes from Peds ICUs, not NICUs. Drug infusions, such as with fentanyl and midazolam, are especially good at generating dependency. Withdrawal signs and symptoms from the two drugs overlap, making it hard to separate the two in weaning. Aquired Opioid and/or Benzodiazepine Dependency For those infants who receive prolonged cumulative exposure to these two classes of drugs, the AAP offers some guidelines. Each clinical unit needs to establish its own dose levels above which withdrawal is likely. As a rule for fentanyl infusions, a cumulative fentanyl exposure of >2 mg/kg or >7 days duration predicts a likelihood of dependency of over 50%, but less than 100%. These infants should go into a weaning schedule over weeks. Infants who do not reach the cumulative exposure to either opioids or benzodiazepines can be weaned rapidly. In such cases, many of the infants will not withdraw (BUT, some will). If withdrawal occurs after a rapid wean, it is usually within 24 hours of the last dose. Aquired Opioid and/or Benzodiazepine Dependency As previously mentioned, withdrawal from benzodiazepines overlaps the signs and symptoms of NAS. Once weaning has been established, iv benzodiazepines can be converted to oral lorazepam. The weaning duration will be proportional to the length of treatment with the iv benzodiazepine. Clinical Highlights/Summary Every nursery (my version) should develop a protocol that defines indications and procedures for screening for maternal substance abuse. Additionally, a standardized plan should be in place for evaluating and treating infants at risk for or showing signs of withdrawal or drug effect. Infants with known intrauterine exposure to opioids and benzodiazepines should be observed in the hospital for 4-7 days. Outpatient follow-up should be early. Breastfeeding, if safely possible, may help reduce the risk of withdrawal. Finally, there is still a lot we do not know about the effects of drug dependency and drug exposure in neonates. Jennifer McKee, Pharm D Neonatal Abstinence Syndrome and Associated Health Care Expenditures JAMA, May 9, 2012;307(18);1934-1940. This article was a retrospective cross-sectional analysis of national samples using several large databases. Authors were from the University of Michigan. Infants with NAS were identified from a cross-sectional analysis of pediatric discharges in 2000, 2003, 2006, and 2009 using the Healthcare Cost and Utilization Project’s Kids’ Inpatient Database (KID). The database samples 80% of pediatric discharges and 10% of uncomplicated births. Using the KID, NAS patients were identified using the ICD-9-CM code of 779.5 (drug withdrawal syndrome in a newborn). Using another database, the Nationwide Inpatient Sample (NIS), delivering mothers were identified by common delivery diagnosis related groups. Neonatal Abstinence Syndrome and Associated Health Care Expenditures JAMA, May 9, 2012;307(18);1934-1940. Iatrogenic NAS was looked for by searching NICU discharge data for the diagnoses of very low birth weight, PVL, IVH, NEC , spontaneous bowel perforation, or BPD. Data would probably have been more accurate if search included pulmonary hypertension, ECMO, and congenital heart disease. Conclusions Between 2000 and 2009 total hospital charges for NAS were estimated to have increased from 190 to 720 million dollars (includes inflation). The CDC found that the sales and deaths related to opiate pain relievers quadrupled between 1999 and 2008. The majority of costs related to NAS are shouldered by Medicaid. We are no better at getting infants with NAS home than we were in 2000. Based on national data comparing 50 states and the District of Columbia, Indiana ranks… 28th in preterm births* (12.4%) * less than 37 completed weeks gestation 29th in low birth weight* (8.3%) * less than 2,500 grams 18th in deliveries via cesarean section (30%) 39th on 1st trimester entry into prenatal care (63.3%) 39th in infant mortality (7.8) 36th in percent of babies who are ever breastfed (70.5%) Indiana received a grade of C on the March of Dimes 2011 Premature Birth Report Cards