Perinatal Substance Exposure: Challenges
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Perinatal Substance Exposure: Challenges
Priya Jegatheesan, MDBalaji Govindaswami, MBBS, MPH
Division of Neonatology, Santa Clara Valley Medical Center, San Jose.
August 12th, 2014
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ObjectiveScope of the problem of substance abuseBiology of addiction in adult vs. newbornsChallenges in the care of newborns exposed
to substances in utero
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Substance Abuse – Global ProblemAlcohol – causes
6% of global death
Drugs3.4-6.6% adults
use drugs1 % of deaths
attributable to drugs
Annual Prevalence and number of illicit drug users at the global level, 2010
Prevalence (%) Number (thousands)
Low High Low High
Cannabis
2.6 5.0 119,420 224,490
Opioids 0.6 0.8 26,380 36,120
Opiates 0.3 0.5 12,980 20,990
Cocaine 0.3 0.4 13,200 19,510
Amphetamine–type
0.3 1.2 14,340 52,540
Ecstasy 0.2 0.6 10,480 28,120
Any illicit
3.4 6.6 153,000 300,000http://www.unodc.org/documents/data-and-analysis/WDR2012/WDR_2012_web_small.pdf
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Substance Abuse – National Problem: SAMHSA 201224 m (9%) used illicit substance in the last monthMost common is Marijuana – 7%Methamphetamine 0.2-0.3%Non-medically used prescription drugs 2.6%Dependence – 8.5% Pregnant women – 5.6% used illicit drugs (lower
than in non-pregnant (10.7%) population; 15-17 y – 18%
http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.pdf
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Maternal co-morbiditiesPsychiatric illness
Depression, Anxiety disorders45% Axis 1 diagnosis, 75% Axis 2 diagnosis
PsychosocialLower socio-economic status & educational levelAdverse Childhood Experiences:
Abuse – emotional, physical, sexualDysfunctional household Substance abuse Mental illness Domestic violence Incarceration separation
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Maternal co-morbiditiesInfections – HIV, Hep B, Hep CTransmission
IV, blood products, sexual transmissionRisk Factors
IV drug useRisky sexual related behaviorRisky drug related behaviorImmunocompromised
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Biology of Addiction – Reward Pathway
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Biology of AddictionVTA – dopaminergic neurons tell the individual if the
stimuli is rewarding or aversiveNA – GABAergic neurons mediate the rewarding effectAmygdala – establishes conditioned learning, learns
associations to environmental cues and the rewarding experience.
Hippocampus – establishes memory associated with reward experiences
Pre-frontal cortex – glutamatergic neurons controls the executive function that mediates drug seeking behavior.
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Biology of Withdrawal in Newborns
Physical signs of withdrawal from opiates is mediated by Neuro EpinephrineNeurons in LocusCeruleus in Mid Brain.
LC – Neurons have Mu receptors , Alpha 2 Adrenergic receptors that decrease NE via adenyl cyclase – cAMP - PKA
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Biology of Withdrawal in Newborns
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Challenges in CareUniversal Screening vs. Risk Based
Scoring; Toxicology: Urine vs. Meconium vs. Cord vs. Hair
Score for Withdrawal - which score, when to score, how to score, when to treat
Treatment options only for opiate withdrawal: opiates vs. phenobarb vs. clonidine
Breastfeed or notDischarge planning difficulties: home with
mom or foster care
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Screening for Substance ExposureUniversal Standardized questionnaire
Non-judgementalTrauma informed care 5Ps, … etc.
ToxicologyUrine Meconium Hair / Umbilical cord
Legal Implications Consent CPS referral
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Withdrawal ScoresOnly for opiate withdrawalFinnegan Score vs. ModifiedStandardized, inter rater reliability – staff
educationWhen to score – before or after feedsPolysubstance abuse may impact the scores
(nicotine withdrawal etc.) however it is used specifically to treat opiate withdrawal
Encourage Parental involvementOptimize non-pharmacological measures
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Medical treatment for NASOpiate agonist – Morphine / methadone acts
on Mu receptorsClonidine – Alpha 2 adrenergic agonist –
suppresses noradrenergic mediated sympathomimetic symptoms of withdrawal
Phenobarbital - GABAergic agonist, but also blocks AMPA (excitatory) receptor, also non-specific to other receptors in brain
Ondansetron – 5HT antagonist – decreases the withdrawal symptoms in animals / adults
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BreastfeedingUncertain pharmacokinetics of illicit drugs
in mothers and newbornsAdulterants in the drugs Variable excretion into breastmilkCo-morbid psychiatric illnessPsychiatric medications Viral infections that are contraindications
(HIV, HSV with active lesions on the breast)
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Recommendations from ABM and AAP
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Challenges with breastfeedingComplicated recommendationsMedical team often ineffective in making
social assessmentsMedical drugs vs. Illicit drugsMarijuana – medical / non-medicalWhen in hospital, do you initiate
breastfeeding and then evaluate, pump and dump, discourage ……..
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Discharge PlanningDifficult social situation, lack of a support
systemUnstable / unsafe home environmentLack of adequate residential treatment
programs for mother and babiesOutpatient Perinatal Substance Abuse
Programs Foster care vs. discharge with biological
mother with CPS supervisionBreastfeeding but at still at risk of relapse
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AcknowledgementSubstance exposed mothers and newborns at
SCMVCSCVMC MCH StaffPerinatal Substance Abuse Program at SC County
Santa Clara First FiveVMC FoundationVON iNICQ Collaborative
NIH Funding for Prevention of NAS studySAMHSA Advisory group – MAT NAS