Perinatal Substance Exposure: Challenges

Priya Jegatheesan, MDBalaji Govindaswami, MBBS, MPH

Division of Neonatology, Santa Clara Valley Medical Center, San Jose.

August 12th, 2014

ObjectiveScope of the problem of substance abuseBiology of addiction in adult vs. newbornsChallenges in the care of newborns exposed

to substances in utero

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

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

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

Maternal co-morbiditiesInfections – HIV, Hep B, Hep CTransmission

IV, blood products, sexual transmissionRisk Factors

IV drug useRisky sexual related behaviorRisky drug related behaviorImmunocompromised

Biology of Addiction – Reward Pathway

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.

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

Biology of Withdrawal in Newborns

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

Screening for Substance ExposureUniversal Standardized questionnaire

Non-judgementalTrauma informed care 5Ps, … etc.

ToxicologyUrine Meconium Hair / Umbilical cord

Legal Implications Consent CPS referral

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

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

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)

Recommendations from ABM and AAP

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 ……..

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

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