Neonatal Abstinence Syndrome (NAS)

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Neonatal Abstinence Syndrome (NAS). LaResa Janousek , RN, NNP-BC Idaho Perinatal Project February 21, 2013. Objectives. Increase awareness of opioid use and pregnancy. Identify and screen for maternal opioid use/abuse. Describe the clinical characteristics of Neonatal Abstinence Syndrome. - PowerPoint PPT Presentation

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Neonatal Abstinence Syndrome (NAS)

LaResa Janousek, RN, NNP-BCIdaho Perinatal ProjectFebruary 21, 2013ObjectivesIncrease awareness of opioid use and pregnancy.

Identify and screen for maternal opioid use/abuse.

Describe the clinical characteristics of Neonatal Abstinence Syndrome.

Understand how to manage patients with NAS.

Recognize the importance of parental support and involvement.Increase awareness of the problem of prescription drug abuse.Identify high risk mothersRecognize NASUnderstand how to initiate and manage therapy in patients with NAS.Parent involvement

2TopicsThe Problem

NAS assessment and treatment

Parent communication and education

The ProblemAssessing intrauterine drug exposureNeonatal Abstinence Syndrome (NAS) Patient communication and education

3OpioidNatural and synthetic drugs with morphine-like properties, although the chemical structure may differ from that of morphine. 2Endogenous opioids include enkephalins, endorphins, and endomorphins.

Opioid is a general term for both natural and synthetic drugs with morphine-like properties, although the chemical structure may differ from that of morphine. 2Endogenous opioids include enkephalins, endorphins, and endomorphins.Opioids are used mostly for their analgesic properties to treat pain.

Opioids demonstrate a narrow therapeutic index. On the other hand, the interpatient range of dose necessary to achieve a similar therapeutic effect is fairly wide because of genetic differences in pharmacokinetics and pharmacodynamics.narcotic analgesic used in the treatment of severe pain. Illicit heroin may be smoked or solubilised with a weak acid and injected. Whereas opium has been smoked since historical times, diamorphine was first synthesised in the late nineteenth century. opioids, produces analgesia. It behaves as an agonist at a complex group of receptors (the , and subtypes) that are normally acted upon by endogenous peptides known as endorphins. Apart from analgesia, produces drowsiness, euphoria and a sense of detachment. Negative effects include respiratory depression, nausea and vomiting, decreased motility in the gastrointestinal tract, suppression of the cough reflex and hypothermia. Tolerance and physical dependence occur on repeated use. Cessation of use in tolerant subjects leads to characteristic withdrawal symptoms. Subjective effects following injection are known as the rush and are associated with feelings of warmth and pleasure, followed by a longer period of sedation. Diamorphine is 23 times more potent than morphine. The estimated minimum lethal dose is 200 mg, but addicts may be able to tolerate ten times as much. Following injection, diamorphine crosses the bloodbrain barrier within 20 seconds, with almost 70 % of the dose reaching the brain. It is difficult to detect in blood because of rapid hydrolysis to 6-monoacetylmorphine and slower conversion to morphine, the main active metabolite. The plasma half-life of diamorphine is about three minutes. Morphine is excreted in the urine largely as the glucuronide conjugate. Diamorphine is associated with far more accidental overdoses and fatal poisonings than any other scheduled substance. Much morbidity is caused by infectious agents transmitted by unhygienic injection.

4Opioid UsesInduce or supplement anesthesia.Cough suppressants.Gastrointestinal disorders.Analgesic properties to treat pain.Opioid addiction.

Induce or supplement anaesthesia: fentanyl, alfentanil and remifentani).Cough suppressants: codeine, dihydrocodeine and, to a lesser extent, pholcodine and ethylmorphine)Treat gastrointestinal disorders: codeine and diphenoxylate.Treat opioids addiction: buprenorphine, suboxone and methadone.1)

5Opioid Use for Pain Analgesics: disconnect from painEuphoria, disconnection, sedationOversedation, respiratory depression

fentanylhydromorphoneMethadonemorphine pethidinebuprenorphineOxycodonecodeinedihydrocodeine dextropropoxyphene

Opioids are used mostly for their analgesic properties to treat:

Codeine, heroin (diacetylmorphine),hydromorphone (Dilaudid), fentanyl(Sublimaze), and methadone areexamples of synthetic opioids.

Methadone exertssecondary effects by acting as anN-methyl-D-aspartate receptor antagonist,blocking the actions of glutamate,the primary excitatory neurotransmitterin the CNS. Opioids acutely inhibitthe release of noradrenaline atsynaptic terminals. With chronic opioidexposure, tolerance develops asthe rate of noradrenaline releaseover time increases toward normal.Abrupt discontinuation of exogenousopioids results in supranormal releaseof noradrenaline and producesthe autonomic and behavioral signsand symptoms characteristic of withdrawal.3

6

Drug TrendsDrug addiction is a mental illness: characterized by compulsive drug craving, seeking, and use despite devastating consequences.that stem from drug-induced changes in brain structure and function.

Drug Addiction

Drug addiction is a mental illness. It is a complex brain disease characterized by compulsive, at times uncontrollable drug craving, seeking, and use despite devastating consequencesbehaviors that stem from drug-induced changes in brain structure and function. These changes occur in some of the same brain areas that are disrupted in other mental disorders, such as depression, anxiety, or schizophrenia.For example, compared with the general population, people addicted to drugs are roughly twice as likely to suffer from mood and anxiety disorders, with the reverse also true.

8Health and social consequencesExacerbated medical conditionsInadequate treatment Resistance to seek treatment

*http://oas.samhsa.gov/nsduh/2k9nsduh/2k9Results

Drug Abuse Consequences9Drug use impacts patient outcomes and has wide-ranging health and social consequences.Medical conditions such as cardiovascular disease, stroke, cancer, HIV/AIDS, anxiety, depression, sleep problems, as well as financial difficulties and legal, work, and family problems can all result from or be exacerbated by drug use.Only a fraction of individuals who need specialty treatment for drug or alcohol addiction receive it.In 2009, of the more than 23 million persons aged 12 or older who needed specialized treatment for a drug or alcohol problem in the United States, nearly 21 million did not receive it.*Many patients who abuse substances won't seek treatment on their own.Nearly 95 percent of those who did not receive treatment felt that they did not need it.**http://oas.samhsa.gov/nsduh/2k9nsduh/2k9Results

Characteristics of Chemically Involved Pregnant WomenLow self-esteem Limited family support Hx of violent or unhealthy relationships Likely to be victims of early sexual or physical abuse Limited educationFrequently unemployedProblems maintaining adequate stable housing Little prenatal carePoor parenting skillsHx of dysfunction/chemically dependent familiesNeed for a wide range of services Poly drug use Mental health problems

Because of their chemical dependency and lack of information about prenatal care, pregnant substance abusers are more likely than other women to have poor nutrition before and during the time they are pregnant. Many women also smoke cigarettes; the number one cause of poor birth outcome is smoking. Physical and sexual abuse of children with parents addicted to either alcohol or opiates is as high as 22% in one study of 200 families. If neglect was included, the incidence rose to 40%. Parents who must devote a major portion of their energy and financial resources to their habit have less left over for the child. Violence, disorganization and criminality in the family are more common. All of these factors compromise maternal health and place the developing fetus at risk.

10Drug Abuse in PregnancyPoly-drug abuse is commonLess likely to receive prenatal careIncreased risk of associated infectious diseases, including syphilis, gonorrhea, hepatitis, and HIVIncreased incidence of psychiatric disorders

11Drug Abuse in Pregnancy4.3% of pregnant women ages 15-44 self-reported illicit drug use in past month, and may actually be as high as 15-30% National Survey on Drug Use and Health (2002-2003)Opiate use in pregnant women ranges anywhere from 1% to 21%.1 Tobacco use in pregnancy: 20.3% 20Alcohol use in pregnancy: 14.8% 20

1220 National Household Survey on Drug Abuse 1996-1998. Marijuana = 2/3; Cocaine = 1/10. Any illicit drugs: 2.8% 20 Rate of drug use decline by 24% from 1st to 3rd trimester. At time of delivery in Perinatal Substance Exposure Study Group, nicotine found in 8.8%, alcohol 6.7%, and any illicit drug 3.5%Neonatal Withdrawal Syndrome

Neonatal Abstinence Syndrome (NAS)60% to 80% of newborns exposed to opioids in the womb are reported to have NAS signs and symptoms.

Neonatal Withdrawal Syndrome is a set of problems that newborns experience when they are exposed to addictive substances while they were in their mother's uterus. Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome caused by maternal opiate use. 60% to 80% of newborns who had been exposed to methadone or heroin while in the womb are reported to have NAS signs and symptoms.However, there are not national estimates on how many newborns in the USA have NAS symptoms due to maternal opiate use.Not all infants show the same effects from prenatal exposure to alcohol and other drugs. Effects depend upon the genetic factors, maternal health, access to health care, chemicals used, patterns of use, duration of use and health care received. The following characteristics have been observed in infants exposed prenatal:

Withdrawal can continue for weeks or months, damaging parent-infant bonding, as well as the babys cognitive and social development. Perhaps the saddest effec