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March 6, 2017
A Partnership for Treatment of NAS
Eastern Maine Medical Center and
Penobscot Community Health Center
Key Vocabulary • NAS – Neonatal Abs6nence Syndrome, withdrawal from
prenatal exposure to opiates -‐ treated or not • Addic(on is the use of mood altering substance(s) or
behavior(s) characterized by impaired control, preoccupa6on, con6nued use despite consequences, and denial
• Therefore: Newborns are not ADDICTED • Recovery is an ACTIVE process of change through which an
individual achieves abs6nence from the addic6ng substance and improves his/her health and may involve Medica(on-‐assisted recovery
Metro Clinic Opens 10/2005
Discovery House Opens 9/2007
Acadia Clinic Opens 2001
What’s the Trickle-‐down of the Increase in Replacement Therapy for Mothers?
7 15 15 15
15 15 20
11 14
0
20
40
60
80
100
2008 2009 2010 2011 2012 2013 2014 2015 2016
EMMC Maternal Opiate Exposures for Annual NAS Admissions [N = 1516]
Methadone
Buprenorphine
Prescribed
Illicit
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Treatment of Neonatal AbsKnence Syndrome
• 5-‐day minimum inpa6ent stay to observe for withdrawal mee6ng treatment threshold
• Non-‐pharmacologic approach: – Higher calorie nutri6on to maintain weight gain – Minimal s6mula6on environment – Swaddling/bundling – Rooming in – Support breast feeding
• Pharmacologic treatment: – Methadone our preferred if pharmacologic treatment is used -‐> change
to 12 hour dosing for outpa6ent discharge
0%
10%
20%
30%
40%
50%
Methadone Buprenorphine Prescribed Illicit Penobscot Co
22%
12%
23%
41%
9%
Prematurity Rate (
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Take Home Messages • Addic6on is not a morally based weakness or personality flaw • The language we use with each other and with the families we serve has
more power than we may realize. • Even brief interven6ons can be effec6ve and beneficial. Mo6va6onal
interviewing is key. • These families are not easy to work with! Other mental health diagnoses
are ojen present. Taking care of yourself will allow you to con6nue taking care of them.
• Know your own stuff/biases/baggage. • Do not underes6mate the complexity of emo6ons felt by a mother (or
father) of an infant who is experiencing withdrawal. • Knowledge is power and the experiences of the educated vs the non-‐
educated are vastly different. • Families who are affected by substance abuse are best served by
knowledgeable, competent, and compassionate caregivers who recognize that addic6on is a neurologically based disease and is treatable.
OUTPATIENT TREATMENT OF NAS??
Are you kidding me?
Why consider OutpaKent Treatment for Neonatal AbsKnence Syndrome? Advantages to families • Supports mother’s recovery • Empowers the family to care for their newborn • Enhances amachment opportuni6es • Diminishes stress of judgment (real or imagined) in this
vulnerable popula6on
Why consider OutpaKent Treatment for Neonatal AbsKnence Syndrome?
Advantages • Free-‐up acute care inpa6ent space • Decrease costs to healthcare system • Changes our care paradigm away from decreasing length of stay
– Decreasing length of Hospital stay unfortunately forces us to find the edge of tolerable withdrawal as we decrease doses
– This reinforces poor state control in these high-‐risk infants – Can’t be good for the developing brain – Moves us away from even considering 2nd drugs since we use
these as a crutch to support inpa6ent weaning • Why do we do this? To get these babies and families out of the
hospital, so why not focus on that in the first place??!!
Concerns by Providers • Decreased opportunity for assessment and ‘scoring’ of newborn
– Can I trust the parents for this? • Puts methadone in the hands of the parents and in the home
– Can I trust the parents for this? – Risk of overdose – Will other caregivers be involved? – Risk of sibling taking methadone
• Decreased interac6on with family • Imposes barriers of transporta6on, weather, and other demands that can interfere
with gepng to appointments • Depends on Safety net and relies on community resources • Risk of “Lost to follow-‐up” during treatment?
First paKent born 5/28/14 Discharged 6/11/14
Methadone 0.12mg Q12h Off methadone 7/2/14
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OutpaKent Treatment of NAS??
It Takes a Community
CollaboraKon
Community Partners • Social Work at EMMC • Care Management (PCHC) • DHHS • Pharmacy • NICU • Penobscot Pediatrics • Community PCP’s • Public Health Nursing • Maine Families
Process begins at EMMC
Baby iden6fied for Pharmacological treatment by NICU staff Cleared by Social Work, DHHS Criteria reviewed-‐
– Transporta6on – Understand need to come weekly – Family support
Discussion with parents regarding the commitment that Champ Clinic includes
Accept Decline
Referral made ajer
collabora6on with medical provider
Parents are
provided a Champ
Handbook
Nursing staff
provide educa6on to parents
Champ Clinic Intake Mee6ng held
Discharge Day
CoordinaKon with Penobscot Pediatrics • Receive referral
– Start chart in EMR at PCHC – EMMC social worker coordinates discharge mee6ng with PCHC care manager
– Discharge plan mee6ng held at EMMC – Inpa6ent Nurse teaching
• Medica6on administra6on and scoring
Discharge • Medica6on dispensed from PCHC prior to discharge
• Follow up with PCP in 2 days
• First CHAMP clinic visit following Tuesday
• Weekly CHAMP visits un6l stable-‐ then every other week
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CHAMP Appointment
• MA Check in – pa6ent roomed, vitals
• MA Collect and count syringes, document syringe count and discard waste
• MD Review score sheets • MD Discuss wean and symptoms • MD Prescrip6on printed • CM faxes script, prints weaning
schedule, gives new score sheets
Aaer clinic
• Family checks out • Pharmacy prepares medica6on
• Family takes paper copy to pharmacy and brings lock box
• Pharmacy fills lock box, takes paper copy
• Family home with baby
MedicaKon • Methadone 5 mg / 5 ml oral solu6on • Dosing every 12 hours • Usually no wean first week (O.3-‐0.4 mg bid) • Wean by .02 mg per dose every 3/4 days vs every 7days
• When dose is at .06 mg twice daily, wean to once daily for 3-‐4 days then every other day for 3-‐4 days, then off
• Phenobarbital 6/59 babies required
Child Welfare • 7/59 Babies in DHHS custody from NICU
– 1 reunified with birth mother • 4/52 Babies into DHHS custody during CHAMP clinic treatment
• 1/35 in kinship care during treatment • 20% -‐ out of home placement
Age and Dose at NICU Discharge
Average Age: 15.77 days Average Dose: .35 Q mg
Length of Hospital Stay for InpaKent and OutpaKent NAS Treatment (n=39)
6/2014 to 2/2015
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Weeks in Clinic
Average Weeks in Clinic: 15
How are the babies doing? • Well Child Check-‐up when PCP is a PCHC provider [61%]
• NICU follow up clinic encouraged • Child Developmental Service referrals made
• Audiology Evalua6on follow-‐ups • Ophthalmology • Monthly check-‐in mee6ngs with Maine families, PHN, DHHS
Grant and Community Support • City of Bangor • Penquis Regional Linking Project • All Saints Catholic School, Bangor • Maine Community Founda6on • EMMC Seed Grant for Registry
Resources
Popula6on Health Management 2015 Lee • Compared inpa6ent to inpa6ent/outpa6ent program • Decreased LOS 55% • Success depends on appropriate caregivers, dedicated
outpa6ent program with educated, experienced medical provider team, case management, access to pharmacy with capability to dispense methadone
Resources
Outpa6ent Management of Neonatal Abs6nence Syndrome: A Quality Improvement Project 2016 • First published QI study looking at inpa6ent/outpa6ent model of care for
comprehensive mul6disciplinary treatment of NAS using methadone monotherapy
• Involves well coordinated care by providers, • Involves educa6on and involvement of parents • Can decrease inpa6ent LOS • Plan to inves6gate effects of dura6on of outpa6ent treatment and long term
neurodevelopmental outcomes of cumula6ve methadone dose
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Resources
NAS Ar6cles
● NEJM 2015 Tolia
● Popula6on Health Management 2015 Lee
● ASTHO Neonatal Abs6nence Syndrome Companion Report
● NEJM 2016 McQueen
● Outpatient Management of Neonatal Abstinence Syndrome: A Quality
Improvement Project 2016 Chau
● Center for Disease Control and Prevention 2016 Ko
Our first CHAMP