Alice Ordean, MD, CCFP, MHSc, FCFP, DABAM Medical Director, Toronto Centre for Substance Use in Pregnancy (T-CUP), St. Joseph's Health Centre ...
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Alice Ordean, MD, CCFP, MHSc, FCFP, DABAM
Medical Director, Toronto Centre for Substance Use in Pregnancy
(T-CUP), St. Joseph's Health Centre, Toronto, ON
February 1, 2017
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
8Rate 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
10Utilization 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
11Overview 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
13Highlights 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
16Routine 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
17Women 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).
181. 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.
193. Every pregnant opioid using woman and her partner
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.
4. Methadone Maintenance Treatment (MMT) is the
standard of care for the management of opioid use
disorders in women during pregnancy.
205. Buprenorphine Maintenance Treatment (BMT) may
be considered as an alternative to methadone for
the management of opioid use disorders in women
during pregnancy.
6. If methadone or buprenorphine are not available,
other sustained-release preparations may be
considered for the management of opioid use
disorders in pregnancy.
217. Referral to Child Protection Services (CPS) should be
considered on a case-by-case basis.
8. During labour and delivery, the pregnant woman
should continue to take her daily dose of opioid
agonist treatment to avoid withdrawal.
9. Additional pain management (i.e. analgesia) may be
required for women on opioid agonist treatment.
2210. 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.
2324
25
12. Identification of infants with NAS should be based
on the mother’s antenatal history and the care
provider’s clinical assessment/ suspicion.
2613. 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.
2728
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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.
3315. 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.
3417. Breastfeeding should be recommended and
supported in methadone/ buprenorphine-
maintained mothers, assuming absence of absolute
contraindications.
18. Preventive skin care should be initiated at birth to
prevent excoriation.
3519. Cardio-respiratory monitoring is recommended for
all infants started on morphine and continued for 4
days and/or until the dose is reduced. Further
monitoring should then be at the discretion of the
physician in charge.
3620. Morphine should be considered the first line
pharmacological treatment of NAS when supportive
measures fail to adequately ameliorate the signs of
withdrawal.
21. Infants whose signs of withdrawal are difficult to
control on morphine may require an additional
medication such as clonidine or phenobarbital.
37Medication Dosing Guidelines
Morphine
Morphine is indicated when three consecutive scores are ≥ 8 according to the Score Oral Morphine Dose
Standardized NAS Scoring Tool or when the average of two scores or the score 8-10 0.32 mg/kg/day divided q4-6h
for two consecutive intervals is 12. 11-13 0.48 mg/kg/day divided q4-6h
If the scores remain ≥ 8 for 3 consecutive scores or ≥ 12 on 2 occasions, the 14-16 0.64 mg/kg/day divided q4-6h
morphine dose is increased to the next range i.e. by 0.16 mg/kg/day. If 0.80 17 + 0.80 mg/kg/day divided q4-6h
mg/kg/day fails to control signs of withdrawal, morphine may be increased to
0.96 to 1.0 mg/kg/day. Clonidine (see below) should be considered at this
point.
Weaning:
Weaning is initiated when scores areMedication Dosing Guidelines
Clonidine
Clonidine has been explored as a possible therapeutic option in combination 0.5 -1 mcg/kg orally q4-6h
with morphine. There is Level 1 evidence from one small randomized Much higher doses (0.5 to 3 mcg/kg/h)
controlled trial demonstrating that clonidine in addition to standard opioid have been used as a continuous infusion
therapy reduces the duration of pharmacotherapy for neonatal abstinence.39
Therefore clonidine may be considered as an adjunct to morphine when high Please Note:
doses (see above) fail to control withdrawal symptoms. Adequate clinical trials to establish an efficacious
and safe dose still are required
Some studies gradually increased doses over 1 to 2 days to begin therapy, and
tapered doses by 0.25 mcg/kg every 6 hours to discontinue (or by 25% of the
total daily dose every other day).
39Medication Dosing Guidelines
Phenobarbital
Phenobarbital may be used in combination with morphine in infants exposed Oral Morphine Dose
to polysubstance abuse (sedatives, alcohol or barbiturates in addition to Score in combination with
opiates). Phenobarbital
8-10 0.16 mg/kg/day divided q4-6h
Phenobarbital 10 mg/kg is given every 12 hours for 3 doses, then 5 mg/kg/day 11-13 0.32 mg/kg/day divided q4-6h
is continued as a maintenance dose. The doses of morphine used in 14-16 0.48 mg/kg/day divided q4-6h
combination with phenobarbital are lower than those given when morphine is 17 + 0.62 mg/kg/day divided q4-6h
used alone.
4022. A primary health care provider who is comfortable
following a baby with NAS should be confirmed
prior to discharge.
4123. Discharging the infant home on morphine should only be
undertaken if the clinical team is confident that the social
risk is low, the infant is stable and there is a clear and
comprehensive plan for weaning the infant and a designated
supervisor of that plan is identified, who will follow the
infant with, at minimum, a weekly visit.
Following consultation with the clinical team, the final
decision to discharge an infant on pharmacological treatment
is at the discretion of the physician.
4224. Every baby exposed to opioid agonists and other
substances should be offered ongoing
developmental assessments by a clinical expert.
43Summary and Discussion 44
• Narcotic use in Ontario and NAS rates increasing
• Prevention of pregnancy is paramount to influencing
incidence of NAS
• Pregnancy offers high motivation to change
• MMT/ BMT assist with relapse prevention and stabilizing
social risks
• Supporting family is most promising intervention to
facilitate optimal management of NAS
45• The physical factors of NAS are complex but treatable
• Need consistent approach
• The psychosocial factors of NAS are much more
complicated
• Addressing psychosocial risk factors is critical to ensuring
positive life changes, newborn safety and overall family
wellness
46The recommendations produced by the Work Group expert
panel provide the framework which has the potential
to reduce both the incidence and the impact of NAS through:
• implementation of prevention strategies
• assessment of risk
• standardization of both maternal and neonatal treatment
47http://www.pcmch.on.ca/wp-content/uploads/2016/12/NAS-
Clinical-Guideline-Update-2016Nov25.pdf
48Thank you everyone who participated in the original Work Group
and contributed to the development of the 2010 NAS Clinical
Practice Guidelines.
Thank you to those who volunteered their time and contributed
to the development of the 2016 guidelines update:
• Alice Ordean
• Kim Dow
• Henry Roukema
• Christina Cantin
49You can also read
