Neonatal Abstinence Syndrome Sean Loudin MD Candice Hamilton

Neonatal Abstinence Syndrome Sean Loudin MD Candice Hamilton, MPH

Disclosures I have no financial disclosures

Objectives Understand the mechanism of withdrawal Discuss the definition of NAS Understand the local incidence of NAS across the state Discuss quality improvement surrounding NAS Explore “new” exposures that babies may be affected by

Drugs Causing Withdrawal

Drugs Causing Withdrawal Classic NAS due to opiates Nicotine withdrawal from maternal tobacco exposure Irritability associated with marijuana Alcohol withdrawal and birth defects Delayed withdrawal secondary to maternal benzodiazepine or psychotropic medications

Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome Passive exposure of the newborn occurs when a mother uses a neuroactive drug during her pregnancy When the infant is deprived of these substances through the birthing process, a withdrawal syndrome may develop

Neonatal Abstinence Syndrome Classic NAS consists of a wide variety of CNS signs of irritability, GI problems, autonomic signs of dysfunction, and respiratory symptoms The hallmark of neonatal withdrawal is a striking disorder of movement, most aptly termed “jitteriness” ~Volpe 2008

Neonatal Abstinence Syndrome Autonomic over-reactivity is typically exhibited by yawning, sneezing, mottling and fever Cerebral irritation results in an irritable and hypertonic infant ~Oei and Lui 2007

Pathogenesis of NAS

Pathogenesis of NAS Endogenous opiates (endorphins, enkephalins and dynorphins) Complex interactions between endogenous opiates and their receptors are important in the developing brain Locus coeruleus is a nucleus in the brain stem (pons) where norepinephrine is synthesized and involved with physiological response to stress and panic

Pathogenesis of NAS Opiates activate opiate receptors in the locus coeruleus in the brain stem Decrease in c. AMP production Increase in K+ efflux Decrease in Ca 2+ influx Decrease in norepinephrine release

Pathogenesis of NAS

Pathogenesis of NAS When the opiate is withdrawn, the inhibiting effect gone This results in a supranormal increase in norepinephrine levels, which are the likely cause of the signs and symptoms of NAS

Pathogenesis of NAS Disuse Hypersensitivity A drug may depress certain neural systems Render the targets hypersensitive to their usual stimuli Removal of the depressing drug results in a rebound hypersensitivity of the affected targets May be caused in part by an increase in synthesis of certain receptors ~Volpe 2008

Pathogenesis of NAS Alternate Pathways Drug may depress a primary neural pathway An alternate pathway, usually of minor activity, may become more prominent in attempt to compensate When the drug is removed, both pathways may operate in an additive fashion ~Volpe 2008

Pathogenesis of NAS Alternative Pathway Disuse Hypersensitivity

Drugs in WV

Drugs in WV Prevalence of Drug Use in Pregnant West Virginia Patients Chaffin et al. 2009 During 1 month period (August 2009) all cords at 8 hospitals were tested 759 total samples collected, 146 (19. 2%) were positive for drugs and/or alcohol Of the positives 40% marijuana, 28% opiates, 27% alcohol, 12% bezos, 10% methadone, <1% amphetamines and 0% were positive for cocaine or buprenorphine

Drugs in WV 2014 West Virginia Perinatal Partnership – Explore a Pay-for-Success QI project Asked WV Medicaid to pull numbers of NAS infants Meeting in September 2014

WV NAS Definition ICD-10 (P 96. 1) When a baby has prenatal exposure to a neuroactive substance and exhibits clinical signs/symptoms of withdrawal, regardless of whether pharmacological treatment is required.

NAS Coding ICD-9 ICD-10 779. 5 P 96. 1

Maternal Exposure Codes ICD-9 alcohol 760. 71 anticonvulsants 760. 77 antifungals 760. 74 anti-infective agents 760. 74 antimetabolics 760. 78 cocaine 760. 75 "crack" 760. 75 hallucinogenic agents 760. 73 medicinal agents NEC 760. 79 narcotics 760. 72 obstetric anesthetic or analgesic drug 763. 5 specified agent NEC 760. 79 Smoking complicating pregnancy, childbirth, or the puerperium 649. 0 ICD-10 P 04. 0 Newborn affected by maternal anesthesia and analgesia in pregnancy, labor and delivery P 04. 1 Newborn affected by other maternal medication P 04. 2 Newborn affected by maternal use of tobacco P 04. 3 Newborn affected by maternal use of alcohol P 04. 4 Newborn affected by maternal use of drugs of addiction P 04. 41 Newborn affected by maternal use of cocaine P 04. 49 Newborn affected by maternal use of other drugs of addiction P 04. 5 Newborn affected by maternal use of nutritional chemical substances P 04. 6 Newborn affected by maternal exposure to environmental chemical substances P 04. 8 Newborn affected by other maternal noxious substances P 04. 9 Newborn affected by maternal noxious substance, unspecified

WV Birthscore October 2016 Began collecting data Intrauterine Substance Exposure (includes any medication prescribed by a physician during pregnancy). Yes/No (if No, questions below will not be available) If yes, then check all that apply Self-reported Documented in prenatal record Positive maternal drug test Unknown Other Infant with clinical signs consistent with NAS diagnosis? Yes/No

WV Birthscore Oct 1, 2016 -March 31, 2017 Intrauterine Exposure 1384/9614 (14. 4%) NAS 541/9614 (5. 6%) Among those infants exposed, 39% were diagnosed with NAS Among those 1, 384 exposed: 86. 42% WV residents 69. 4% WV Medicaid 27. 31% born <37 weeks GA Among the 541 w/ Signs of NAS: 85. 21% WV residents 70. 61% WV Medicaid 25. 88% born <37 weeks GA

WV Birthscore October November December January February March Intrauterine Exposure 12. 26% (208) 15. 23% (240) 15. 22% (252) 14. 65% (223) 15. 4% (248) 13. 7% (213) NAS 5. 37% (91) 5. 77% (91) 6. 58% (109) 5. 52% (84) 5. 4% (87) 5. 1% (79

WV Birthscore Cabell Huntington Hospital January 2017 186 live births Birthscore Chart Audit Exposed 27 (14. 5%) 29 (15. 6%) NAS 10 (5. 4%) 20 (10. 7%) 41 tobacco exposed (22%) 21/29 of the Substance Exposed also Tobacco Exposed

WV vs Nation Patrick et al. “Increasing Incidence and Geographic Distribution of Neonatal Abstinence Syndrome: United States 2009 -2012” J Perinatol. 2015 Aug; 35(8): 650– 655.

WV vs Nation Neonatal abstinence syndrome (NAS) incidence rates* — 25 states, 2012– 2013† WV NAS incidence in 2013 33. 4 Source: State Inpatient Databases, Healthcare Cost and Utilization Project Ko JY, Patrick SW, Tong VT, Patel R, Lind JN, Barfield WD. Incidence of Neonatal Abstinence Syndrome — 28 States, 1999– 2013. MMWR Morb Mortal Wkly Rep 2016; 65: 799– 802. DOI:

What’s Next

What’s Next Gabapentin (Neurontin) Imodium (Loperamide) Marijuana Increased THC concentration “BHO” and “Shatter” K 2 Something?

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