Alice ice Ordean dean, MD, CCFP, MHSc, FCFP, DABAM Medical Director, Toronto Centre for Substance Use in Pregnancy (T-CUP), St. Joseph's Health Centre, Toronto, ON Febr bruary uary 1, 201 017
Part 1 • Background • Overview of 2010 NAS Work Group • Highlights of Key Changes in Updated Guidelines (2016) Part 2 • Presentation of Updated Maternal and Newborn Recommendations and Implementation Resources (2016) • Summary and Discussion 2
Part 1 – Background 3
• Canada is the world’s second -largest per capita consumer of opioids • Ontario has the highest rate of narcotic use in Canada • 2014 U.S. National Survey on Drug Use and Health: ~5% of pregnant women reported illicit drug use in past 30 days, 0.2% heroin use and 1% non-medical use of prescription opioids Canadian Centre on Substance Abuse. 2015 Prescription Opioids. http://www.ccsa.ca/Resource%20Library/CCSA-Canadian- Drug-Summary-Prescription-Opioids-2015-en.pdf 4
Maternal opioid use (prescribed or illicit) during pregnancy is associated with negative pregnancy and neonatal outcomes: • Premature delivery • Intrauterine growth restriction, Low birth weight • Neonatal abstinence syndrome (NAS) • Possible adverse long-term effects 5
Definition: • A constellation of symptoms and signs in newborn due to withdrawal from in utero drug exposure • Neurological (high-pitched cry, exaggerated startles, increased tone) • Gastrointestinal (poor feeding, vomiting, loose stools) • Respiratory symptoms • Regular maternal drug use during the last two weeks preceding birth is a risk factor for NAS 6
• Canada: • 3.8 infants out of 1,000 births • Ontario: • 0.9 infants out of 1,000 births (2002-2003) • 5.1 infants out of 1,000 births (2011 – 2012) Canadian Centre on Substance Abuse. 2015 Prescription Opioids. http://www.ccsa.ca/Resource%20Library/CCSA-Canadian- Drug-Summary-Prescription-Opioids-2015-en.pdf 7
• Canada: • 3.8 infants out of 1,000 births • Ontario: • 0.9 infants out of 1,000 births (2002-2003) • 5.1 infants out of 1,000 births (2011 – 2012) Canadian Centre on Substance Abuse. 2015 Prescription Opioids. http://www.ccsa.ca/Resource%20Library/CCSA-Canadian- Drug-Summary-Prescription-Opioids-2015-en.pdf 8
Rate of Neonatal Abstinence Syndrome (per 1,000 Births) 7.0 6.0 Rate per 1,000 Births 5.0 4.0 3.0 2.0 1.0 0.0 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 Ontario National Data Source: CIHI DAD; Birth Data extracted from Statistics Canada http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo04a-eng.htm 9
• Prolonged length of stay in hospital for specialized care and support to both the baby with NAS and the mother/family • Increased utilization of scarce resources in the Level II and III neonatal units • Possible developmental and psychological problems may pose long term challenges requiring support from the health care system, social services and the education system 10
Utilization of Beds per Day for Infants with NAS as Any Diagnosis (Ontario) 1,200 40.0 Number of Infants with NAS NAS Beds Utilized per Day 35.0 1,000 30.0 800 25.0 600 20.0 15.0 400 10.0 200 5.0 0 0.0 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 NAS Beds Utilized per Day Number of Infants with NAS Data Source: CIHI DAD; Birth Data extracted from Statistics Canada http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo04a-eng.htm 11
Overview of 2010 NAS Work Group 12
• Provincial task force comprised of experts in clinical care and social support of pregnant women and high risk infants • Conducted an environmental scan and literature review of social and medical interventions for the management of NAS secondary to opioid use • Developed recommendations for harm reduction strategies and optimal management of NAS = Neonatal Abstinence Syndrome Clinical Practice Guidelines 2012 13
Highlights of Key Changes in Updated Guidelines (2016) 14
• Smaller group of experts reconvened in May 2016 to update the guidelines Key changes between 2012 and updated 2016 versions: 1. Overall more streamlined and condensed recommendations 2. Updated references to support recommendations and expanded list of resources under Implementation Considerations 3. Removed routine toxicology testing recommendation [e.g. “Toxicology testing may be done on all known and suspected cases of NAS .” – 2012 NAS Clinical Practice Guidelines]
Part 2 – NAS Clinical Practice Guidelines 2016 16
Routine screening by primary health care providers of all women of childbearing age for use of licit and illicit substances, namely opioids, is recommended as part of the routine health history. • Can lead to early identification of women at risk for opioid use • Helps normalize the conversation about this sensitive topic • Screening should be comprehensive and not restricted to opioid use only (polysubstance use) • Positive self-report may indicate a need for assessment using a validated screening tool and/or a more comprehensive evaluation by a specialist 17
Women who are identified to have an opioid use disorder should be educated about the risks that continued opioid use may have on their reproductive health, including pregnancy. Contraception counseling should be a routine part of substance use treatment among women of reproductive age, in order to minimize the risk of unplanned pregnancy (especially when a woman switches to sustained-release opioid agonist preparations such as methadone or buprenorphine). 18
1. Health care providers should routinely screen all pregnant women for use of opioids and other licit and illicit substances. 2. Every pregnant opioid using woman should be offered comprehensive care, including obstetrical care, addiction care, community care, and psychosocial counselling and support. 19
Every pregnant opioid using woman and her partner 3. and family should receive written material explaining NAS, hospital stay expectations, the role of the parent, and resource contacts, in order to prepare and educate the opioid using woman and her support persons. Methadone Maintenance Treatment (MMT) is the 4. standard of care for the management of opioid use disorders in women during pregnancy. 20
Buprenorphine Maintenance Treatment (BMT) may 5. be considered as an alternative to methadone for the management of opioid use disorders in women during pregnancy. If methadone or buprenorphine are not available, 6. other sustained-release preparations may be considered for the management of opioid use disorders in pregnancy. 21
Referral to Child Protection Services (CPS) should be 7. considered on a case-by-case basis. During labour and delivery, the pregnant woman 8. should continue to take her daily dose of opioid agonist treatment to avoid withdrawal. Additional pain management (i.e. analgesia) may be 9. required for women on opioid agonist treatment. 22
10. Narcotic antagonists (e.g. naloxone, nubain) should be avoided as they are contraindicated in women with opioid use disorder. 11. Implement a partnership plan that focuses on all aspects of infant care, including feeding, handling, skin- to-skin care, rooming-in, and the frequency of follow-up visits after the mother is discharged, in order to enhance communication between care providers and parents, and to support the parents’ involvement in the care of their infant. 23
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12. Identification of infants with NAS should be based on the mother’s antenatal history and the care provider’s clinical assessment/ suspicion . 26
13. A Standardized NAS Scoring Tool is recommended to assess suspected or known cases of in utero opioid exposure: a) In cases of exposure to short-acting preparations of opioids, infants should be scored for a minimum of 72 hours. b) In cases of exposure to sustained-release preparations of opioids, infants should be observed for 120 hours, since onset of withdrawal may be delayed. c) Infants should be scored with each care interaction, typically every 2-4 hours. 14. Mother-baby dyad care, including rooming-in or care-by-parent, should be promoted . 27
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Non-pharmacological interventions should be utilized for all infants with NAS. Pharmacological interventions should be considered for the treatment of NAS when non-pharmacological measures fail to adequately ameliorate the signs of withdrawal. • Medication is indicated when 3 consecutive scores are ≥8 on the Standardized NAS Scoring Tool or when the average of 2 scores or the scores for 2 consecutive intervals is ≥12. 33
15. The baby’s environment should be modified to reduce sensory stimulation, including limiting visitors, minimizing overhead lighting, and decreasing noise. 16. Soothing behaviours, positional support, swaddling, gentle handling, kangaroo care, and frequent, hypercaloric, smaller volume feedings are beneficial and should be considered in the treatment of newborns with NAS, both in the hospital and the home environment. 34
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