New Neonatal Abstinence
Syndrome
in NICU
Dr. Darshan Shah
Asst. Professor of Pediatrics
Quillen College of Pediatrics

Drug use in general population

How Common or Uncommon it is?

Prescribed/Illicit/Not intended
New Neonatal Abstinence
Syndrome
in NICU
2010 Data of National Drug Survey:
 High School Senior : 1 in 3 used medical
prescription or OTC drug for Non-Medical
reason #### 33%%%
 Pregnant women 18-25 years 23% Vs
13% Non pregnant

New Neonatal Abstinence
Syndrome
in NICU

Why rise in narcotic prescription?

What it takes to get prescription?

What it makes easy or difficult in
pregnancy?
New Neonatal Abstinence
Syndrome
in NICU
MMT shifted from FDA to Center of
Substance Abuse and Addiction in 2001
 Standard for Methadone prescription not
well defined and not uniformly followed
 More philosophy to “treat and better
outcome”
 Rise in number of ‘Pain Clinics” last
decade

New Neonatal Abstinence
Syndrome
in NICU
Pain Clinics
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DC Recovery
Memphis TN
(901) 375-1050
Atenley Drug Center
Greenville
TN
(423) 639-5255
DRD Knoxville Medical Clinic
Knoxville TN
(865) 522-0161
DRD Knoxville Medical Clinic Central
Knoxville TN
(865) 5220661
Jackson Professional Associates
Jackson TN
(731) 660-0880
Memphis Treatment Center for Research and Addiction Treatment
Memphis TN
(901) 722-9420
Middle Tennessee Treatment Center
Nashville TN
(615) 3212575x104
Midsouth Treatment Center
Dyersburg
TN
(731) 2856535
Raleigh Professional Associates
Memphis TN
(901) 372-7878
Solutions of Savannah
Savannah
TN
(731) 925-2767x2760
The Mustard Seed
Newport TN
Volunteer Treatment Center Inc
Chattanooga
3122
Pain clinics in TN
TN
(423) 265-
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Western Carolina Treatment Center
Ashville
ADS Alcohol and Drug Services
Burlington
NC
Alcohol and Drug Abuse Treatment Ctr
Butner
McLeod Addictive Disease Center Charlotte
NC
Metro Treatment of North Carolina LP Charlotte Treatment Center
Mountain Area Recovery Center West
Clyde
BAART Community Healthcare
Durham
NC
Durham Treatment Center
Durham
NC
Carolina Treatment Center (CTC) Fayetteville
NC
Metro Treatment of North Carolina LP Fayetteville Treatment Center
McLeod Addictive Disease Center Gastonia
NC
Alcohol and Drug Services ADS East
Greensboro
Greensboro Metro Treatment Center
Greensboro
PORT Human Services Methadone/IV Programs
Greenville
Walter B Jones Alcohol and Drug Abuse Treatment Ctr Greenville
McLeod Addictive Disease Center Hickory
Hickory
Alcohol and Drug Services ADS West
High Point
Jacksonville Treatment Center
Jacksonville
NC
McLeod Addictive Disease Center Marion
Marion
McLeod Addictive Disease Center Monroe
NC
Carolina Treatment Center of Pinehurst
Pinehurst
Raleigh Methadone Treatment Center (RMTC)
Raleigh
Rocky Mount Treatment Center
Rocky Mount
NC
Sanford Treatment Center LLC
Sanford
NC
McLeod Addictive Disease Center Statesville
Statesville
New Hanover Metro Treatment Center
Wilmington
Wilmington Treatment Center
Wilmington
NC
Insight Human Services
Winston Salem
NC
NC
(336) 532-0500
NC
(704) 332-9001
Charlotte
NC
(925) 726-1063
(919) 286-1509
(910) 864-8739
Fayetteville
(704) 865-1558
NC
NC
NC
NC
NC
NC
(910) 347-2205
NC
(704) 332-9001
NC
NC
(252) 972-4357
(919) 776-0711
NC
NC
(800) 992-3671
(336) 725-8389
Pain clinics in NC
(828) 251-1478
(919) 575-7928
NC
(828) 454-0560
(704) 697-0044
NC
(910) 483-0958
(336)
(336)
(252)
(252)
(828)
(336)
333-6860
273-9611
353-5346
830-3426
464-1172
882-2125
(828) 659-3966
(910) 235-9090
(919) 781-5507
(704) 871-2992
(910) 251-6644
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What it takes to get prescription for pain?
History of Heroine/IV drug use/Morphine
History of illicit
Hydrocodone/Percocet/other drugs
History of chronic pain(?) not relieved by
other medicine
History of anxiety/nervousness
Pain Clinic

Methadone is used to relieve moderate to severe pain
that has not been relieved by non-narcotic pain
relievers. It also is used to prevent withdrawal
symptoms in patients who were addicted to opiate
drugs and are enrolled in treatment programs in
order to stop taking or continue not taking the drugs.
Methadone is in a class of medications called opiate
(narcotic) analgesics. Methadone works to treat pain
by changing the way the brain and nervous system
respond to pain. It also works as a substitute for
opiate drugs of abuse by producing similar effects
and preventing withdrawal symptoms in people who
have stopped using these drugs.
Reason to Use Methadone
According to NID

What all these medications use has done?
Pain Clinics
Effects of
Illcit/prescribed/Abused
medication
Effects on Mortality
Incidence Across States

2000:
1.7/1000

2003:
2.2/1000

2006:
3.1/1000
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2009:
5.7/1000
Data Regarding Maternal Drug Use
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2000:
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2003:
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2006:
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2009:
1.5
1.9
2.3
2.9
NAS rate
Maternal drug use and NAS
Newborn Vs NAS baby

Which is better?
◦ Methadone
◦ Subutex (Bupronorphine)
◦ Suboxone (Bupronorphine and
Naloxone)
Maternal Medication
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Methadone:
Only recommended treatment for
pregnant women till recently (2007-8)
Longest experience in pregnancy
Full mu-opioid agonist
Dose: 40 mg to 120 mg
Minimum possible dose
Maternal Medication
Methadone:
 Earlier studies shown treatment with
methadone better than “street drug; no
treatment or detox” during pregnancy
regarding preterm birth, infectious
complication, neonatal death and
maternal morbidity.
 So it became “standard of care” for IVD
and other illicit opioid drug

Maternal Medication
Problems after Methadone:
 Higher incidence of NAS
 It depends on dose, duration and other
concomitant drugs
 Umbilical cord level of EDDP (Ethylene
Dimethyl Diphenylpyrolidine) correlates
NAS better than Methadone concentration

Maternal Medication
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Subutex (Buprenorphine)
Partial-mu-oipiod agonist and kappaopioid antagonist
◦ Less than maximal opioid effect
◦ Diminished risk of overdose
◦ Minimal risk from abrupt
withdrawal
◦ Dose: 4 mg to 30 mg
Maternal Medication
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Trial of Methadone Vs Subutex
Drugs and Alcohol: only 20 patients
combined
It showed Subutex not inferior to Methadone

NEJM 2010: 131 Neonates were part of
study.
Drugs 2012: Meta analysis

Results

Maternal Medication
Buprenorphine exposed newborn required
 significantly less morphine
 Shorter duration of treatment
 Shorter hospital stay

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So what’s problem?
Maternal Medication

Dissatisfaction rate was 71% in Subutex
group versus13% in Methadone group in
NEJM trial.

Main barrier for use of Subutex
Maternal medication
Suboxone ( Buprenorphine and naloxone
in 4:1 combination)
 Combination of partial mu Opioid receptor
agonist with opioid antagonist
 When taken by sublingual route no effect
of Naloxone only Buprenorphine like
Subutex effect but when injected/Parental
route it causes withdrawal in opioid
dependent subjects

Maternal Medication
Doses: 4/1 , 8/2 and 16/4
 No direct comparison with Methadone but
essential same as Subutex when taken as
a sublingual tablet

Maternal Medication
Newborn

When born to drug exposed mother what
to expect and when to expect?

How to diagnose Neonatal Abstinence
Syndrome (NAS) or Maternal Medication
Withdrawal Syndrome ?
Newborn
NAS: CONSTELLATION OF SIGNS AND
SYMPTOMS RESULTING FROM
DYSFUNCTION OF
 Autonomic nervous system
 Gastrointestinal tract
 Respiratory system

NAS

Finnergan Scoring System

Most widely used screening method
What’s significant score?
NAS
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Treatment:
Nonpharmacological
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Noise/light/distraction free QUITE
atmosphere
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Bundle care

Hyper caloric feeding
NAS
NAS
Medication
 Morphine: 0.1mg/kg q 4 hrs
 Methadone: 1mgkg q 24 hrs
 Clonidine: 0.5 -1 by mouth every 6 hrs
 Phenobarb: 2-5 mg/kg every 12 hrs
NAS
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Future treatment
Ondansetron (Zofran)
Immunomodulator
Vaccine
Genetic
NAS
NAS
Thank you

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GO DAWGS : SEC EAST CHAMPION
NAS