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Illicit Drugs and their effects on fetus/newborn
Presented by: Cynthia PatrelloInova Fair Oaks NICU-2015
Cocaine
Occurs naturally in coca plant- then extracted and refined. Extracting the alkaloid results in coca paste then refined to cocaine hydrochloride.Crack- processed from cocaine by adding baking soda and heating it until it forms small pellets. It is then cooled and filtered to make “rocks” that are smoked in a pi[e.Metabolized into numerous compounds: benzoylecgonine (Urine metabolite), ecgonine,
and ecgonine methyl ester.
Cocaine cont…
Normally grown in South America (Andean). Some grown in India, Africa and Indonesia.On SPECT exam- the brain looks like mini-strokes on the surface.Studies show that after being drug-free for 6 months there is still underactivity in the frontal and temper-parietal brain regions.Deficits in attention, concentration, new learning, visual and verbal memory, word production
Cocaine cont.
With long term use- there are blood flow deficits and persistent intellectual compromise. Crack users show a 23% decrease in cerebral blood flow. Cigarette smoke increased the percentage to 42%.Used in combination with other drugs: injected with heroin (speedball), smoked with PCP (tick) smoked with marijuana (turbo) Following a binge the “crash” lasts from 9 hours -4 days- agitation, depression, insomnia. Withdrawal lasts 1-3 weeks- paranoia, anxiety.
Cocaine-
Cocaine in the brain - In the normal communication process, dopamine is released by a neuron into the synapse, where it can bind with dopamine receptors on neighbouring neurons. Normally dopamine is then recycled back into the transmitting neuron by a specialised protein called the dopamine transporter. If cocaine is present, it attaches to the dopamine transporter and blocks the normal recycling process, resulting in a build-up of dopamine in the synapse which contributes to the pleasurable effects of cocaine.
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Cocaine
Normal Brain
Brain on Cocaine
Heroin comes from Poppies
How Heroin can be packaged
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Heroin
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Heroin-Black Tar
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Copyright © 2015 www.aboutheroin.com
Track marks
Heroin
The seedpod of the Poppy is dried then powdered to make opium. Opium contains several alkaloids one being morphine. Morphine concentration in opium ranges from 4-21%Average purity of heroin is 38%Heroin addicts daily dose is 5-1500mg. Positive morphine in urine- use within 2-3 days. Quickly crosses the blood-brain barrier and converted to morphine, then rapidly binds to opioid receptors.
Heroin Cont.
The limbic system has an abundance of opioid receptors causing happiness, relaxation, fearlessness and pain tolerance. The receptors are flooded with morphine which produces a sensation of pain-free euphoria and relaxation. This causes rapid addiction. After initial rush follows several hours of “nodding off”Long term effects cause molecular and neurochemical brain changes.
Heroin
Heroin is often cut with various substances to reduce the purity.; sugar, starch, powdered milk, strychnine and other poisons and drugs such as Fentanyl.Sometimes additives won’t dissolve and after injection can clog blood vessels (to lungs, liver, kidneys or brain and infecting or even killing cells in vital organs)Experience rush within 7-8 seconds IV5-8 minutes IM and 10-15 min. smoked or sniffed.
Heroin
Withdrawal symptoms occur if stopped abruptly or even reduced. Begins within 6-12 hours from last dose and lasts 5-10 days. Watery eyes, runny nose. Major withdrawal peak between 48-72 hours- irritability, diarrhea, Nausea, vomiting, abdominal cramps, muscle spasms, bone pain and severe depression.The chronic user will have skin “sores” on face and arms that they pick.
Meth effects in just years
Usual doses:
Amphetamines 10-30mg. Common Amphetamines Names- Biphetamine, Dexedrine: Tolerant individuals take up to 2000mg/d.Half life can be 7-34 hrs depending on urine ph. Serum detection 46 hours after ingesting 10mg.Usually 1-3 days.
Methamphetamine- 5-10mg.Tolerant individuals dose is much higher.Half-life varies on dose; between 10-30 hours.Smoking 22mg as base or (“Ice”) detectable in urine for 60 hours at 300ng/ml.
Cocaine- usual dose 20-100mg.Half life- 20mg- 1 hour; 100 mg- 6 hours.Serum detection 20mg-4-6 hours; 100mg at 12 hours. Average being 5.1 days in chronic users.Benzoylecgonine- main metabolite- detected in urine 1-2 days after IV of 20mg. Chronic users- using more than 10mg/day- detected in urine up to 22 days.
Opiates: Heroin and Morphine- usual beginning dose of 10mg. Chronic users 1-2 g/day.Half life- heroin-2-7 minutes; morphine 2-3 hours.Detection in urine 11-54 hours.Associated with severe decrease in blood flow. Worse brain damage is caused by Heroin.
Opiates
Ecstasy (MDMA)- usual dose 50- 100mg.Half-life 7-8 hoursDetectable in serum- 24 hours; urine 1-3 daysMDMA acronym for Methylenedioxymethamphetamine.
Cannabis-the dose absorbed after smoking between 5-30mg.Half life of THC (tetrahydrocannabimol) 30 minutesDetection in urine- 34 hours with maximum detection up to 95 days.
Fentanyl- Street names: Goodfella, Jackpot, Murder 8, TNT, Tango.Injected, smoked, snortedDetected in urine- 8-24 hours.
Oxycodone- Oxycontin, Oxy, O. C. killerMethod of use- oral, nasal, injectedDetected in urine 8-24 hours.
Hydrocodone- Vicodin: Vike, Watson-387Taken orally.Detected in urine 1-6 days.
Methadone-( Dolophine) Method of use- oral or injectedDetected in urine 6-12 days.
Buprenorphine (Subutex, Buprenex, Temgesic, Suboxone) Method of use- oral or injected.Detected 1-6 days.
Barbiturates- Amytal, Nembutal, Seconal, Phenobarbital (barbs, reds, red birds, tooles, yellows, yellow jackets) Method of Use- oral or injected Detection in urine- 2-10 days.
Benzodiazepines- Ativan, Halcion, Valium, Xanax (candy, downers, sleeping pills, tanks)Method of use- oral, injectedDetection in urine 1-6 weeks.
Nicotine- cigarettes, cigars, smokeless tobacco, snuff, chewComes from tobacco plants. The tobacco plants natural protection from insects is nicotine. Use of tobacco crops insecticide is being blamed for killing honey bees.One drop of the toxin has been proven to be as lethal as strychnine and in animal studies 3 X deadlier than arsenic.Detected in urine 4-30 days.
NicotineCNS stimulant activating the fight or flight response resulting in a stimulated high.Nicotine peak levels within 10 seconds of inhalation.Higher serum concentrations in placenta, amniotic fluid and fetal serum than maternal.Second hand smoke is more toxic than if you inhaled the smoke. Contains more than 250 chemicals with at least 69 being cancerous.
Nicotine
Thirdhand smoke is the accumulation of second hand smoke on surfaces such as clothes, furniture and vehicles that becomes progressively even more toxic. It includes lead, arsenic and carbon monoxide. Can cause breathing problems, learning disorders and cancer. Nicotine is also associated with oral facial clefts.
New DrugsFlakka-Made from chemical in the family of bath salts (Amphetamine)
Bath salts was banned in 2011 however, the component that makes up Flakka (Alpha-PVP- found in bath salts) was not.
User feels extreme anxiety, paranoia and hallucinations. Violent behavior is not uncommon. Extremely high body temperatures leading to kidney damage and muscle breakdown.
Krokodil (Desomorphine)
Originated in Russia. Derivative of codeine.Highly addictiveHome-based manufacturing with gasoline, paint thinner or lighter fluid along with hydrochloric acid and red phosphorus (red tip of matches)
Krokodil Effects
8-10 times more potent than morphine.Fast –actingCaustic to veins: ulcerations, gangreneShort half-life- < 2 hrs. 3 times more toxicBuyers often think they are purchasing Heroin.
K2/Spice
Synthetic marijuanaOther names: Skunk, Yucatan Fire, Fake WeedBanned as Illegal 2012Physical/Psychological Effects- seizures, aggressive behavior, paranoia, high blood pressure, high heart rate, chest pain and schizophrenia.
“Molly” or Ecstasy (MDMA)
Capsule or tablet taken orallyName comes from slang for “molecular”Crystalline powder form of MDMAEffects last 3-6 hours.Usually taken with other drugs-cocaine, meth, ViagaraPhysical effects- increases serotonin, dopamine and norepinephrine. This large release influences mood, appetite and sleep.
Molly cont….
This large release of serotonin actually depletes the chemical in the brain- this causes confusion, depression, drug craving and anxiety.Heavy use causes attention problems and memoryHigh doses can cause hyperthermia- resulting in kidney or cardiovascular system failure or death.
IFOH Chemistry LabUrine Drugs of Abuse Cut-Off Levels
Amphetamines 1000ng/mlBarbiturates 200ng/mlBenzodiazepines 200ng/mlCocaine and Metabolites 300ng/mlOpiates 300ng/mlPhencycidine (PCP) 25ng/mlTHS (Marijuana) 50ng/ml
Quest-Infant Drug Abuse-Meconium
Preferred 5 g fresh meconiumMinimum 1gRefrigerated ( 7 days)Room temperature for only 48 hours.30 days frozen
Quest cont… Cut off levels
Amphetamines 100ng/gBarbiturates 100ng/gBenzodiazepines 100ng/gCocaine 100ng/gMarijuana 20ng/gOpiates 100ng/gMethadone 50ng/gPCP 10ng/g
Clinical Presentation
Appear physically and behave normally at birth.Withdrawal can begin shortly after birth and up to 2 weeks of age. Average within 72 hours.Acute symptoms can last several weeks.Sleeping problems, feeding problems, irritability and hypertonia may last from 4-6 months.
Where do we start???
Screening
Maternal factors- Send urine toxicology on mothers with:
No prenatal care or < 5 visits Hx of drug use/abuse within past year Hx of positive toxicology screens during pregnancy and/or previous pregnancy
Infant Screening
Positive maternal drug abuse through history or urine toxicology.Send urine and /or meconium for drug screenUmbilical cord screen can also be used.Start NAS screening at 2 hours of lifeAssess scoring at least every 4 hours.Score 30-60 minutes after feeding.
Drug Identification
Drugs mother used during pregnancyTiming and amount of last useInclude amount of cigarettes smokedIF the maternal use of opioids is more than a week before delivery- the incidence of NAS is decreasedThe longer the half life of the drug, the later the withdrawal occurs. .
I
Withdrawal
Studies on withdrawal from nicotine have shown abnormal newborn behavior immediately after birth up to 5 days with the findings being more consistent with drug toxicity as opposed to NAS.Also associated with a decrease in milk production, decrease weight gain in infant.
Nicotine on Neonate
Associated with prenatal nicotine exposure is impulsivity and attention problemsAssociated with hyperactivity and negative and externalizing behaviors which continue into adult hood showing higher rates of delinquency, criminal behavior and substance abuse. Studies have proven abnormalities in learning and memory, and lower IQ scores.Children around Second hand smoke are more prone to headache, dizziness, low energy and SIDS.
NIcotine
The half life of nicotine is 2.5 hours in adults and 9-11 hours in newborns.
Scoring- Finnegan
Covers 21 symptoms and their degree of severity.Sleep- 2 High-pitched at its peak or 3 continuous high-pitched.Moro Refelx- Score if jitteriness of hands during or at the end of eliciting Moro Reflex. Score 3 if jitteriness of hands and/or arms or clonusTremors-This is on a scale of increased severity. Whether disturbed or undisturbed (at rest or sleep)
Increased Muscle Tone-Stiff muscles, resistance to passive movements. Excoriation- Skin abrasions ( due to rubbing against surface) Score ONLY when first appear or there’s a new area.Myoclonic jerks- Involuntary, irregular muscle contractions ( usually only single muscle group)Generalized convulsions- Usually seen as tonic extensions of all limbs. Can be limited to one side.
Sweating- only if spontaneous. Not because of excessive clothing or hot roomHyperthermia-(37.2-38.3) 99.0-100.9yearsYawning- > 3 yawns within the scoring intervals. Mottling- If present on chest, arms or legsNasal Stuffiness- congestion or mucous visibleSneezing- > 3 sneezes in scoring intervalNasal Flaring-repeated flaring without other respiratory disease.
Respiratory rate-Counted for full minute. IF > 60. Score 2 if involves retractions.Excessive sucking- Excessive sucking. Increased rooting.Poor Feeding- excessive sucking before feeding but infrequent or uncoordinated during feeding. Regurgitation- one episode even if remains in mouthLoose/watery stools- Loose if curd/seedy Watery if water ring
S/S cont..
Restlessness appears firstMild disturbed tremorsTremors progress to undisturbed.High-pitched cryHypertoniaExaggerated Moro reflex
Disturbed Sleep Patterns
Narcotic withdrawal causes significant sleep disturbances.Studies show that the narcotics obliterate REM sleep patterns thus not allowing for the important deep sleep phase. With proper treatment, REM and normal sleep patterns can be restored.
Seizures
Most serious consequence of withdrawalOccurs in 1-2% heroin-exposed infantsOccurs in up to 7% Methadone exposedNo correlation between amount of drug used and occurrence of seizure.Mean age of seizure is 10 days.These can be generalized seizures or myoclonic jerks.Abnormal EEG occurs ONLY during the seizure!
Respiratory System
There’s abnormal lung compliance and tidal volume in neonates exposed to heroin or methadone evidenced by tachypnea.There is also and increase ph-respiratory alkalosis during the fist week of life.The respiratory alkalosis can cause hypocalcemia and tetany.
SIDS
SIDS is increased by 5-10 times if mothers used additional drugs with Methadone.There’s a 2.5%-4% increase in opiate exposed infant. Studies have shown a disturbance in sleep ventilatory patterns and an impaired protective response to hypoxia and hypercapnia during sleep.
Screening
Prior to pharmacologic treatment other metabolic disorders must be rules out.HypocalcemiaHypomagnesemiaHypothermiaIf the mother has had no prenatal care:
Assess infant for other diseases, IVH and sepsis. Obtain infant urine for toxicology.Meconium- screens for drug use over past 20 weeks.
Pharmacologic Use
Scores of > 8 for 3 consecutive scores2 consecutive scores >12
This is called the 24 Rule.
Chop.edu
Pharmacological Use
If score is =/> 8, increase scoring intervals to every 2 hr. and continue for 24 hours from the last total score of 8 or higher.IF 2 hr scoring is =/< 7 for 24 hours, then 4 hr scoring resumes.If after pharmacotherapy discontinued, score is less than 8 for 3 days, scoring is discontinued. IF pharmacotherapy D/C scores are consistently 8 or above, scoring should be continued for following 4 days minimum.
Pharmacologic InterventionMorphine- 0.08-.2mg/dose PO every 3-4 hours.Dilution is 0.4mg/mlAdvantage- Diminishes bowel motility and therefore helps loose stools.Disadvantage- Respiratory depression, hypotension, urine retention, delayed gastric emptying.
Cont..
Phenobarbital- Loading doseof 20mg/kg.If score is >/=….10mg/kg every 12 hours.Maintenance dose-2-6mg/kg/day for 3-4 days.
Complications of Excessive Pharmacologic Treatment
Absent or diminished reflexesPersistent mottlingDecreased muscle toneDiminished response to painful stimuliHeart rate 80-100Poor peripheral perfusion
Comfort Measures
Frequent diaper changesPacifierSwaddlingSoft sheets or sheepskinProne or right-sidelying position-reduces risk of aspiration if regurgitation.Mitts over hands to prevent facial scratchingDecreased environmental stimuli- lights, noise.
Documentation
Need to paint a visual picture of what occurred.EX. MOB arrived at 2100 smelling of alcohol and cigarette smoke. Her eyes were red and she reported not sleeping for days. Her clothing was soiled with a distinct smell of body odor. She quickly sat in the chair, never made contact with the baby or asked questions regarding his care and fell asleep. I attempted to awaken her but she fell into a deep sleep snoring. I called Security who was able to come remove the mother from the room and get her home safely.
She was not appropriate to be in the NICU at this time due to her condition. I left a VM for the Case Manager regarding this situation.
Ex. Given by Maria Leathers, SW
