Treating Pregnant and Parenting Women for Substance Use Disorders: Behavioral and Medication Strategies



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Scoring tools for NOWS/NAS

  • Finnegan Neonatal Abstinence Scoring System
    • 31 items
    • Symptoms are weighted
    • Guidelines for pharmacologic treatment at score of 8 or greater
  • MOTHER score (modified Finnegan score)
    • 19 items (which contribute to total score)
    • Items weighted differently
    • Some Finnegan items eliminated and others added
    • Guidelines for treatment based on score rather than weight
  • Lipsitz Neonatal Drug-Withdrawal Scoring System
    • 11 items
    • Items scored for severity and gives guidelines for treatment
  • The Neonatal Withdrawal Inventory – 8 point checklist
  • The Neonatal Narcotic Withdrawal Index – 6 signs plus others
  • Credit: Anne Johnston, MD
  • Jones, Fielder. Preventive Medicine 2015
  • NAS score is not the sole determining factor in the decision to start pharmacotherapy for NAS
  • Score can be affected by
    • State of infant
    • Painful stimuli
    • Order of score
    • “Motive” of scorer

All NOW instruments have common features of summing item scores and/or weighting the severity of presenting signs.

  • All NOW instruments have common features of summing item scores and/or weighting the severity of presenting signs.
  • NOW evaluation is recommended every 3 to 4 hours during hospitalization; surveillance should last for several days after birth and for entire hospitalization.
  • Scores above a threshold trigger medication initiation to reduce NOW severity – no or delayed treatment can result in morbidity or mortality.
  • Stabilization on medication promotes regular eating and sleeping patterns, weight gain, and improved interaction with caregivers.
  • Medication amount is increased then gradually decreased until the neonate is stable without medication.
  • Sarkar, Donn. J Perinatol 2006; Jansson, Velez, Harrow. J Opioid Manag 2009; Jansson, Velez. Pediatr Rev 2011
  • NOW: Measurement and Response

Short-acting opioids (morphine sulfate, dilute tincture of opium)

  • Short-acting opioids (morphine sulfate, dilute tincture of opium)
  • Methadone
    • Inpatient treatment and inpatient to outpatient treatment
    • Symptom versus weight based
    • Allows for shorter length of stay (with outpatient treatment)
    • Endorsed by the AAP (2012)
    • (Several studies including MS Brown et al (2015) which revealed shortened duration of treatment with methadone)
  • Dilute tincture of opium and phenobarbital (Coyle et al, 2002)
    • Decreased severity of withdrawal, decreased length of stay
  • Buprenorphine (Kraft et al, 2011)
    • Shorter length of stay in buprenorphine treated infants
    • Well tolerated
  • Clonidine (Agthe et al, 2009)
    • Oral clonidine as adjunct to short-acting opioids
    • Shortens the duration of therapy, no short-term cardiovascular side effects observed
  • NOWS: Pharmacologic Treatment

NOWS: Non-pharmacologic Treatment

  • Breastfeeding is associated with reduced severity of withdrawal, delayed onset, decreased need for Rx (Abdel-Latif et. al., 2006)
  • Rooming-in decreased the need for Rx, length of Rx, and LOS (Abrahams et. al., 2007)
  • Waterbeds decreased amount of medication needed (Oro et. al., 1988)
  • Acupuncture (Filippelli et. al., 2012)
  • Kangaroo therapy or skin to skin
  • Decreased environmental stimuli
  • Frequent small demand feeds
  • Pacifiers
  • Swaddling, containment, holding, vertical rocking
  • Provider, nursing attitudes
  • Image credits: www.susquehannahealth.org; www.simplymotherhood.com
  • Credit: A Johnston, MD

NOW occurs in the majority of all prenatally opioid-exposed neonates.

  • NOW occurs in the majority of all prenatally opioid-exposed neonates.
  • Medication to treat NOW is required in approximately 50% of the cases.
  • NOW following prenatal exposure to an opioid agonist is best assessed with a standard scoring tool and best treated with an opioid medication.
  • Patients and the providers who treat them will be best served through having a range of medication options from which to tailor treatment.
  • As treatment for maternal opioid dependence advances, so must neonatal treatment (i.e., buprenorphine in the infant may be an important medication for treatment of buprenorphine exposure in utero)
  • Osborn et al. Cochrane Database Syst Rev 2010
  • NOW: Recommendations

All NAS instruments have common features of summing item scores and/or weighting the severity of presenting signs.

  • All NAS instruments have common features of summing item scores and/or weighting the severity of presenting signs.
  • NAS evaluation is recommended every 3 to 4 hours during hospitalization; surveillance should last for several days after birth and for entire hospitalization.
  • Scores above a threshold trigger medication initiation to reduce NAS severity – no or delayed treatment can result in morbidity or mortality.
  • Stabilization on medication promotes regular eating and sleeping patterns, weight gain, and improved interaction with caregivers.
  • Medication amount is increased then gradually decreased until the neonate is stable without medication.
  • NAS: Measurement and Response
  • Sarkar, Donn. J Perinatol. 2006; Jansson, Velez, Harrow. J Opioid Manag 2009; Jansson, Velez. Pediatr Rev, 2011

Later Outcomes

  • Study Name
  • Subgroup
  • Assessment
  • Hunt (2008)
  • 1.5 years old
  • BSID (Psychomotor)
  • Burlowski (1998)
  • GDS (Locomotor)
  • Moe (2002)
  • 1 year old
  • BSID (Psychomotor)
  • Hans (2001)
  • 1 year old
  • BSID (Psychomotor)
  • Hans (2001)
  • 2 years old
  • BSID (Psychomotor)
  • Cognition in opioid and non-opioid-exposed infants
  • Study Name
  • Subgroup
  • Assessment
  • Hunt (2008)
  • 1.5 years old
  • BSID (Mental)
  • Burlowski (1998)
  • 1 year old
  • GDS (DQ)
  • Moe (2002)
  • 1 year old
  • BSID (Mental)
  • Hans (2001)
  • 1 year old
  • BSID (Mental)
  • Hans (2001)
  • 2 years old
  • BSID (Mental)
  • Psychomotor in opioid and non-opioid-exposed infants
  • Credit: A Johnston, MD
  • Credit: A Johnston, MD
  • Study Name
  • Subgroup
  • Assessment
  • Hunt (2008)
  • 3 years old
  • McCarthy
  • Ornoy (2001/2003)
  • 5 years old
  • McCarthy
  • Moe (2002)
  • 4.5 years old
  • McCarthy
  • Walhord (2007)
  • 4.5 years old
  • McCarthy
  • Cognition in opioid and non-opioid-exposed infants
  • Study Name
  • Subgroup
  • Assessment
  • Hunt (2008)
  • 3 years old
  • Ornoy (2001/2003)
  • 5 years old
  • McCarthy Motor Scale
  • Moe (2002)
  • 4.5 years old
  • McCarthy Motor Scale
  • Walhord (2007)
  • 4.5 years old
  • McCarthy Motor Scale
  • Psychomotor in opioid and non-opioid-exposed infants
  • Study Name
  • Subgroup
  • Assessment
  • Hunt (2008)
  • 3 years old
  • Vineland Social Maturity
  • Ornoy (2001/2003)
  • 5 years old
  • Achenbach
  • Moe (2002)
  • 4.5 years old
  • Achenbach
  • Behaviour in opioid and non-opioid-exposed infants
  • Favors non-opioid-exposed
  • Later Outcomes (continued)
  • Baldacchino et al. BMC Psychiatry 2014
  • Credit: A Johnston, MD

UNC Horizons

  • A Model of Integrated
  • Pharmacotherapy and Behavioral Treatment
  • Designed and Implemented to Help Women and Children
  • Trauma and Addiction Treatment
  • Residential
  • Outpatient
  • OB/GYN
  • Employment and Education
  • Psychiatry
  • UNC Horizons
  • Childcare
  • Psychiatry
  • Early Intervention Services
  • UNC Horizons
  • Parenting Education
  • Maternal-Child Psychotherapy
  • Transportation
  • UNC Horizons
  • Outcomes without Horizons
  • UNC Horizons
  • Outcomes with Horizons
  • UNC Horizons
  • Outcomes Compared to NC
  • UNC Horizons
  • Family Outcomes
  • UNC Horizons
  • UNC Horizons saves North Carolina
  • an estimated
  • $3,366,815 every year
  • Estimated Cost Savings
  • UNC Horizons
  • Comprehensive Care
  • Prenatal Care
  • Postnatal Care
  • Substance Abuse Treatment
  • UNC Horizons
  • Trauma-Informed Care
  • Staff trained on trauma-informed care:
    • Staff realizes the widespread impact of trauma and understands potential paths for healing
    • Staff recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system
    • Staff responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings
  • UNC Horizons
  • Prenatal Horizons Clinic
  • Team includes: OB, Nurse practitioner (NP), peer-support specialist, and therapist
  • NP provides primary obstetrical care and manages women taking Suboxone prescribed by the OB
  • Peer-support provides assistance and access to community resources and services
  • Therapists provides counseling
  • Psychiatrist is available as-needed for evaluation and medication management
  • Fielder, Johnson, Jones, Australian nursing & midwifery, 2015
  • UNC Horizons
  • Team educates women on recovery and SUD and supports autonomy
  • Team collaborates with nursery staff to educate women about NAS
  • Incentives to participate in services include:
    • Assistance with parking
    • Gas vouchers
    • Mommy Bucks
    • Transportation
  • Patient Education
  • UNC Horizons
  • Referral and Long-Term Follow-up for Exposed Infants
  • DSS involvement
    • This can and should be seen as supportive, not punitive
    • Often past history with DSS precludes acceptance
  • CDSA referral from the nursery
    • Can be difficult depending on county and resources
  • Ongoing treatment for mother and family
    • Learn your local resources
  • Preschool when available
  • UNC Horizons
  • PCP, OB/GYN, Pediatrician
    • Engage all players before delivery for planning
    • Early testing in mother during gestation in addition to mother and baby at delivery is key
    • Evidence-based protocols exist for Labor & Delivery and Newborn
  • Anesthesiologist
    • Pain management plan
  • Newborn Nursery Team
    • Infant assessment, Finnegan Scales, non-pharmacologic treatments, encourage breastfeeding
  • Neonatal Critical Care Team
    • Symptomatic Infants, Acute Withdrawal
  • DSS involvement
    • This can and should be seen as supportive, not punitive
    • Often past history with DSS precludes acceptance
  • Engage the Team
  • UNC Horizons
  • Postnatal Protocol
  • Visit from child therapist within first week of delivery, even if in NICU
  • Focus on infant strengths, learning infant cues (Hug Your Baby)
  • Continue on going parent education (twice per week)
  • At 6 weeks: Referrals for developmental assessments (Early Intervention) including Speech/Language, Occupational Therapy, Physical Therapy, and Social-Emotional Assessment
  • Support Dyad: Weekly Child Parent Psychotherapy (CPP)
  • UNC Horizons
  • Further support via Parent Education during Substance Use Treatment
  • Attachment-based parenting program: Circle of Security-Parenting© http://circleofsecurity.net
  • Nurturing Parenting Program for Substance Abuse http://www.nurturingparenting.com/
  • Hug Your Baby http://www.hugyourbaby.org/
  • Child Parent Psychotherapy http://www.nctsn.org/sites/default/files/assets/pdfs/cpp_general.pdf
  • Postnatal Evidence-Based Tools
  • UNC Horizons
  • Postnatal NAS Issues
  • Parents need continued education and support at home
  • In the first few months, these infants can be difficult to sooth/irritable, have difficulties transitioning and maintaining sleep, and have feeding issues
  • This can put infants at risk for insecure attachment
  • Parents frequently have other stressors
  • UNC Horizons
  • Why focus on Attachment?
  • Researchers have found that mothers with substance abuse histories:
  • Have repeated relationship disruptions
  • Report more irritable babies
  • Are less sensitive in interactions
  • Are less emotionally engaged
  • Are less attentive
  • Have less positive affect
  • Children from families with substance abuse issues have higher rates of insecure and disorganized attachment.
  • UNC Horizons
  • Summary
  • Treatment for NAS occurs during the pregnancy, post-delivery, and in the home
  • Treatment for mother, infant, and the dyad
  • Focus on strengthening attachment relationship
  • Focus on helping parents learn to read and respond to their infants’ cues
  • Referrals to early intervention paramount
  • UNC Horizons

Summary

  • 1.      Different behavioral interventions and medication assisted treatments can help to increase treatment engagement and reduce drug use among pregnant and/or parenting women
  •  
  • 2.     Neonatal abstinence signs and symptoms can be increased or minimized in response to the care provided as well as other factors. Providers play a key role in helping to support resilience among mothers and their children who have been prenatally opioid-exposed
  •  
  • 3.    The SAMHSA Block Grant provides elements of effective care for pregnant and parenting women.
  • First page credits: “side view of pregnant woman” by imagerymajestic; “mother-child-family-happy-love-1039765/” by the danw; “family eating at the table” by skeeze

Contact:

  • Hendrée E Jones, PhD
  • Executive Director, UNC Horizons
  • Professor, Department of Obstetrics and Gynecology
  • School of Medicine
  • University of North Carolina at Chapel Hill
  • 127 Kingston Drive
  • Chapel Hill, NC 27514 USA
  •  
  • Hendree_Jones@med.unc.edu
  • Direct Line: 1-919-445-0501
  • Main Office: 1-919-966-9803
  • Fax: 1-919-966-9169
  •  
  • UNC Horizons
  • Thank you!
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