Doing the right things for the right reason

Doing the right things for the right reason Proprietary and Confidential Mercy Maricopa Integrated Care

NAS Prevention and Opiate Impact on Newborns Ann Negri, MD, FAPA, DFAPA Proprietary and Confidential

Neonatal Abstinence Syndrome (NAS) NAS is when a newborn baby has withdrawal signs from certain prescription medications or street drugs the mother used during pregnancy. Some of these include: Prescription medications • Methadone • Oxycodone (Oxy. Contin, Percocet) • Codeine, Hydrocodone (Vicodin) • Suboxone • Fentanyl • Ativan (Lorazepam) • Xanax (Alprazolam) • Antidepressants Proprietary and Confidential • Selective serotonin reuptake inhibitors (SSRIs), including Prozac, Paxil, Zoloft, Celexa, etc. • Benzodiazepines (sleeping pills) • Synthetic opioids (Dilaudid, Sublimaze) Illicit drugs • Heroin Mercy Maricopa Integrated Care

Neonatal Abstinence Syndrome (NAS) There were 1, 903 cases of NAS from 2008 to 2014 500 438 450 # of NAS cases 400 339 350 304 2011 2012 223 250 200 150 300 145 154 2008 2009 100 50 0 2013 2014 Source: AZ HDD 2008 -2014 Proprietary and Confidential Mercy Maricopa Integrated Care

NAS and newborn drug exposures in AZ From 2008 to 2014: 235% increase in the rate of NAS cases More than 218% increase in newborns exposed to narcotics White, non-Hispanics made up 68% of the total NAS cases White, non-Hispanics made up 52% of those narcotic exposure cases, while Hispanics made up 28% of them • AHCCCS was the payer in 79% of the overall NAS cases • • From 2013 -2014: • Newborns exposed to cocaine decreased by 39% • Newborns with Fetal Alcohol Syndrome increased by 67% Source: Arizona Department of Health Services, July 2015 Proprietary and Confidential Mercy Maricopa Integrated Care

Neonatal abstinence and newborn drug exposure rates per 1, 000 births Narcotic exposure 218% Increase 9 8 7 NAS births 245% Increase 6 5 4 3 2 1 0 2008 2009 2010 2011 Neonatal Abstinence Syndrome (779. 5) Narcotic Exposure (760. 72) Fetal Alcohol Syndrome (760. 71) Hallucinogen Exposure (760. 73) 2012 2013 2014 Cocaine Exposure (760. 75) Source: Arizona Health Care Cost Containment System Proprietary and Confidential Mercy Maricopa Integrated Care

Concentration of NAS births in the Valley Proprietary and Confidential Mercy Maricopa Integrated Care

Heroin and other substances Proprietary and Confidential Mercy Maricopa Integrated Care

Illicit drug use and associated lifestyle risks Pregnant women who use illicit drugs aren’t just putting their baby at risk – they’re also putting themselves at risk. They have an increase likelihood of getting involved with or facing: • Prostitution • Theft • Violence (becoming victims of violence) • Sexually transmitted infections • Loss of child custody • Criminal proceedings • Incarceration Proprietary and Confidential Mercy Maricopa Integrated Care

Complications from drug, alcohol use during pregnancy Possible complications from drug and alcohol use during pregnancy can lead to many health problems in the baby besides NAS. These may include: • Birth defects, smaller head circumference • Premature birth • Sudden Infant Death Syndrome (SIDS) • Risk for developmental problems, such as cerebral palsy, seizure disorder and mental retardation. Proprietary and Confidential Mercy Maricopa Integrated Care

Use of opioids during pregnancy A 2013 analysis revealed that 645 newborns tested positive for the presence of narcotics. It also found that newborns with NAS, compared to babies without NAS, were: • • • 3 times more likely to have a low birth weight 3 times more likely to have respiratory problems 17 times more likely to have seizures 5 times more likely to have feeding difficulties Staying in the hospital about 13 days vs. a 2 -day stay for a non-NAS newborn Source: Arizona Statewide Task Force on Preventing Prenatal Exposure to Alcohol and Other Drugs Strategic Plan, 2015 -2010 Proprietary and Confidential Mercy Maricopa Integrated Care 11

Symptoms of NAS Symptoms often begin within 1 to 3 days after birth, but may take up to a week to appear. Because of this, the baby will most often need to stay in the hospital for observation and monitoring for up to a week. The type and severity of symptoms depend on various factors, including: • The type, amount and duration of drug used • How mom’s body breaks down and clears the drug (influenced by genetic factors) • Whether the baby was born full-term or premature Proprietary and Confidential Mercy Maricopa Integrated Care

Symptoms of NAS • Blotchy skin coloring (mottling) • Diarrhea • Excessive or high-pitched crying • Excessive sucking • Fever • Hyperactive reflexes • Increased muscle tone Proprietary and Confidential • • Irritability Sleep problems Slow weight gain Stuffy nose, sneezing Sweating Trembling and tremors Vomiting Mercy Maricopa Integrated Care

Long-term effects of prenatal drug exposure The effects of NAS can follow a newborn as they get older. Some of these include: • Behavioral issues and developmental delays • Cognitive delays and impairments, including poor spatial recognition, poor memory recall, hyperactivity and lower IQs • Increased anxiety • Difficulty holding jobs • Difficulty maintaining relationships • Increased risk of drug abuse Proprietary and Confidential Mercy Maricopa Integrated Care

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What happens with at-risk pregnancies Mercy Maricopa’s data shows that most babies remain with their mothers. Some pregnancies are terminated. Newborns also end up in care of family members, adoptive families or the Arizona Department of Child Safety. 377 112 105 Mother CPS/DCS 50 17 29 24 Family Adoption Terminated 2 Stillbirth Other Unknown Termination = ectopic, fetal demise, miscarriage, abortion Unknown = recent delivery, no baby disposition yet Other = mother was out of state or incarcerated during delivery Proprietary and Confidential Mercy Maricopa Integrated Care

Mercy Maricopa’s NAS Program • Identify pregnant women with substance use/abuse issues • Educate them about risks/effects of prenatal exposure to alcohol and other substances • Provide NAS education, discuss treatment options • Talk with members addicted to opioids about a management plan and how prescribing of opioids will be handled during the pregnancy • Emphasize the continued need for regular visits to the obstetrician Proprietary and Confidential Mercy Maricopa Integrated Care

Mercy Maricopa’s NAS Program • • • Support the mother to remain in substance use treatment – before and after the baby is born Begin care management for the infant in the hospital to improve discharge planning and to start parent/guardian training while the baby is in the hospital Identify high-risk and vulnerable parent/child patterns for mothers with dual diagnoses of serious mental illness (SMI) and substance use Screen for depression during and after pregnancy Refer all pregnant SMI members to Southwest Human Development for neonatal evaluation and engagement after delivery Reduce neonatal intensive care unit (NICU) admissions and hospital stays from NAS complications. Proprietary and Confidential Mercy Maricopa Integrated Care

First Connections: A Mercy Maricopasponsored infant mental health program • Pilot with Southwest Human Development started 4 -1 -2016 • Strong coordination of services between adult and children systems of care • Evaluation and support of high-risk and vulnerable parent/child • Integration, coordination of services for infant mental-health specialists and adult members with an SMI determination • Refer all pregnant SMI members to SW Human Development • Engage with mother prior to delivery • Continue relationship with mother to coordinate services in the community Proprietary and Confidential Mercy Maricopa Integrated Care

Southwest Human Development programs There are several resources and programs available to women with newborns who have NAS issues. You can share these with your members/patients. They include: The Children’s Developmental Center (CDC) • The Birth to Five Helpline • The Fussy Baby Program • The Newborn Intensive Care Program (NICP) • Nurse-Family Partnership (NFP) • The Substance Exposed Newborn Safe Environment (SENSE Program) • Smooth Way Home Fragile Infant Project Proprietary and Confidential Mercy Maricopa Integrated Care

Care management with Southwest Human Development It’s important that all mothers with an SMI determination and newborn with NAS issues sign a Release of Information (ROI) form to allow their SMI providers to coordinate care after delivery Proprietary and Confidential

Provider collaboration for treating pregnant women using substances/opioids Behavioral health and addiction services Neonatologists, pediatricians OB Pain managements specialists Proprietary and Confidential MEMBER Medical specialists Parent/infant monitoring from 0 -5 Mercy Maricopa Integrated Care

Infant mental health Why enroll newborns in behavioral health services? • Infants and toddlers depend heavily on adults to help them experience, regulate, and express emotions • Through close, secure interpersonal relationships with parents and other caregivers, infants and toddlers learn what people expect of them and what they can expect of other people • Attachment relationships impact social and emotional development long term Proprietary and Confidential Mercy Maricopa Integrated Care

Supporting a standardized approach to NAS diagnosis Proprietary and Confidential Mercy Maricopa Integrated Care

Keys to reducing NAS CONSIDER substance issues with all pregnant women Proprietary and Confidential DISCUSS substance issues with all pregnant women COORDINATE substance issues with all providers Mercy Maricopa Integrated Care

Considerations while providing care to pregnant women with substance use issues • Close communication between the obstetrician and pediatrician is necessary for optimal care management • All infants born to women who use opioids during pregnancy should be monitored for NAS and treated, if necessary • Treatment is adequate if the infant has rhythmic feeding and sleep cycles and optimal weight gain • Babies born to heroin-addicted mothers are often born addicted to heroin and are at risk for the same potentially life-threatening withdrawal side effects, if not medically maintained and tapered at birth. Center for Substance Abuse Treatment. Medication-assisted treatment for opioid addiction during pregnancy. In: SAHMSA/CSAT treatment improvement protocols. Rockville (MD): Substance Abuse and Mental Health Services Administration; 2008. Available at: http: //www. ncbi. nlm. nih. gov/books/NBK 26113. Retrieved February 9, 2012. Proprietary and Confidential Mercy Maricopa Integrated Care

Considerations while providing care to pregnant women and women of reproductive age • • • Consider possible substance use, including prescription opioids Discuss consequences of substance use and prescription opioid use with all pregnant women and women of reproductive age and explain the risk of NAS for infants exposed to opioids during pregnancy Include information about the patients’ illicit substance use and prescription opioid use during pregnancy to the health plan Proprietary and Confidential Mercy Maricopa Integrated Care

Considerations for treatments, testing • • • Initiate methadone treatment as soon as possible Buprenorphine monotherapy is alternative to methadone Discontinue naltrexone if relapse risk is low No naloxone unless there’s an overdose Discuss breastfeeding with methadone and buprenorphine • Psychosocial treatment is recommended HIV & Hepatitis (B & C) testing and counseling With patient consent, urine testing for opioids and other drugs • • Proprietary and Confidential Mercy Maricopa Integrated Care

Benefits of Medication Assisted Treatment • • Reduce morbidity and mortality Decrease overdose deaths Reduce transmission of infectious disease Increase treatment retention Improve social functioning Reduce criminal activity Evidence-based best practice for treating opioid use disorder (ASAM and WHO) Proprietary and Confidential 29 Mercy Maricopa Integrated Care

Considerations while providing care to pregnant women and women of reproductive age • • Refer all pregnant health plan members with substance use concerns to a High Risk Perinatal Care Management program, which will assist with coordination of care, facilitate collaboration between the primary provider and other providers, and provide education, support and resources to the member. Coordinate with any other providers who are prescribing opioid medications during pregnancy such as behavioral health providers or pain management providers. Utilize medical release of information forms as appropriate for comanagement. Proprietary and Confidential Mercy Maricopa Integrated Care

ROI: A federal requirement to coordinate care Health care providers should maintain frequent communication between the patient’s obstetric care provider and the addiction medicine provider to coordinate care. Remember that the federal confidentiality law (42 CFR Part 2) applies to addiction treatment providers. You’re required to have your patients sign an information release form with specific language regarding substance use before you can share information with other providers. Opioid Abuse, Dependence, and Addiction in Pregnancy - American College of Obstetricians and Gynecologists http: //www. acog. org/Resources-And-Publications/Committee. Opinions/Committee-on-Health-Care-for-Underserved-Women/Opioid-Abuse-Dependence-and. Addiction-in-Pregnancy Proprietary and Confidential 31 Mercy Maricopa Integrated Care

Best practices when providing care to newborns • • • Implement a Screening Protocol for Neonatal Abstinence Syndrome (NAS) and ensure all staff and providers are trained on the protocol. Consider possible NAS when signs and symptoms of substance exposure and/or withdrawal are present even if there’s not a confirmed history of substance use of opioid use in the mother. Implement a Scoring and Treatment Protocol for NAS according to nationally established best practices and ensures all staff and providers are trained on the protocol. • http: //www. pqcnc. org/documents/nasresourc es/VCHIP_5 NEONATAL_GUIDELINES. pdf Proprietary and Confidential Mercy Maricopa Integrated Care

Best practices when providing care to newborns • Encouraging all birthing hospitals to have a written policy on the criteria for screening and testing women and infants for substance exposure. • Working with child protection service (CPS) agencies to review and train staff on policies for reporting substance-exposed newborns. • Staff and provider should be trained in utilizing evidence based NAS screening and treatment protocols • Training should include the recognition of NAS signs and symptoms • Tracking outcomes for CPS referrals made for NAS. Proprietary and Confidential Mercy Maricopa Integrated Care

Best practices when providing care to newborns • Use non-pharmacological treatment for NAS first, followed by pharmacological treatment when warranted • Refer babies with NAS to health plan care management for assistance with coordination of care, resources, support and education of parents/guardian. Proprietary and Confidential Mercy Maricopa Integrated Care

Provider best practices • CHECK THE CSPMP. Providers should review the Controlled Substance Prescription Monitoring Program (CSPMP) for all pregnant women and women of reproductive age at https: //pharmacypmp. az. gov/ • REFER TO PHARMACY RESTRICTION PROGRAM. If you believe your patient may be overusing or misusing controlled substances you should make a referral for possible enrollment into the Health Plan Pharmacy Restriction Program to notify the patient’s care manager or by calling the patient’s Health Plan. Proprietary and Confidential Mercy Maricopa Integrated Care

Provider best practices It’s important to remember that state law requires each medical practitioner who is licensed under Title 32 and who possesses a DEA license to register with the CSPMP. Each DEA license should have an associated registration. There is no fee for this registration, which includes: MD, DO, DDS, DMD, DPM, HMD, PA, NP, ND, and OD. For more information, go to https: //pharmacypmp. az. gov/ or call 602 -771 -2732. Source: Arizona Revised Statute § 36 -2606 Proprietary and Confidential Mercy Maricopa Integrated Care

Provider best practices Arizona law requires a health care professional who “reasonably believes” that a newborn infant may be affected by the presence of alcohol or a drug” to immediate report the information to the Arizona Department of Child Safety. For reporting purposes, “newborn infant” means a newborn infant who is under 30 days of age. You can report by calling 1 -888 -767 -4245 or 1 -888 - SOSCHILD, or online at https: //dcs. az. gov/report-child-abuse -or-neglect Proprietary and Confidential Mercy Maricopa Integrated Care

Provider best practices • Use Arizona Opioid Prescribing Guidelines http: //www. azdhs. gov/documents/audiences/clinicians/clinical -guidelines-recommendations/prescribing-guidelines/az-opiodprescribing-guidelines. pdf • Take the new online course for Arizona DEA prescribers developed by the University of Arizona www. VLH. com/AZPrescribing • Talk to women of childbearing age about NAS Proprietary and Confidential 38 Mercy Maricopa Integrated Care

Resources and references • • Clinical Report: Neonatal drug withdrawal, American Academy of Pediatrics http: //pediatrics. aappublications. org/content/129/2/e 540. full. html Neonatal Abstinence Syndrome: How states Can Help Advance the Knowledge Base for Primary Prevention and Best Practices of Care http: //www. astho. org/Prevention/NAS-Neonatal-Abstinence-Report Arizona Opioid Prescribing Guidelines (November 2014) www. azdhs. gov/clinicians/clinical-guidelines-recomendations/ March of Dimes NAS information Controlled Substance Prescription Monitoring Program (CSPMP) https: //pharmacypmp. az. gov/ http: //www. marchofdimes. org/baby/neonatalabstinence -syndrome-(nas). aspx Mother To Baby Arizona www. Mother. To. Baby. org http: //www. pqcnc. org/documents/nasresources/VCHIP_5 NEONATAL_GUIDELI NES. pdf http: //pediatrics. aappublications. org/content/134/2/e 547 Proprietary and Confidential Mercy Maricopa Integrated Care

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