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Ceccanti M, Blum K, Bowirrat A, Dennen CA, Braverman ER, Baron D, Mclaughlin T, Giordano J, Gupta A, Downs BW, Bagchi D, Barh D, Elman I, Thanos PK, Badgaiyan RD, Edwards D, Gold MS. Future Newborns with Opioid-Induced Neonatal Abstinence Syndrome (NAS) Could Be Assessed with the Genetic Addiction Risk Severity (GARS) Test and Potentially Treated Using Precision Amino-Acid Enkephalinase Inhibition Therapy (KB220) as a Frontline Modality Instead of Potent Opioids. J Pers Med 2022; 12:2015. [PMID: 36556236 PMCID: PMC9782293 DOI: 10.3390/jpm12122015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/14/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
In this nonsystematic review and opinion, including articles primarily selected from PubMed, we examine the pharmacological and nonpharmacological treatments of neonatal abstinence syndrome (NAS) in order to craft a reasonable opinion to help forge a paradigm shift in the treatment and prevention of primarily opioid-induced NAS. Newborns of individuals who use illicit and licit substances during pregnancy are at risk for withdrawal, also known as NAS. In the US, the reported prevalence of NAS has increased from 4.0 per 1000 hospital births in 2010 to 7.3 per 1000 hospital births in 2017, which is an 82% increase. The management of NAS is varied and involves a combination of nonpharmacologic and pharmacologic therapy. The preferred first-line pharmacological treatment for NAS is opioid therapy, specifically morphine, and the goal is the short-term improvement in NAS symptomatology. Nonpharmacological therapies are individualized and typically focus on general care measures, the newborn-parent/caregiver relationship, the environment, and feeding. When used appropriately, nonpharmacologic therapies can help newborns with NAS avoid or reduce the amount of pharmacologic therapy required and the length of hospitalization. In addition, genetic polymorphisms of the catechol-o-methyltransferase (COMT) and mu-opioid receptor (OPRM1) genes appear to affect the length of stay and the need for pharmacotherapy in newborns with prenatal opioid exposure. Therefore, based on this extensive literature and additional research, this team of coauthors suggests that, in the future, in addition to the current nonpharmacological therapies, patients with opioid-induced NAS should undergo genetic assessment (i.e., the genetic addiction risk severity (GARS) test), which can subsequently be used to guide DNA-directed precision amino-acid enkephalinase inhibition (KB220) therapy as a frontline modality instead of potent opioids.
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Affiliation(s)
- Mauro Ceccanti
- Società Italiana per il Trattamento dell’Alcolismo e le sue Complicanze (SITAC), ASL Roma1, Sapienza University of Rome, 00185 Rome, Italy
| | - Kenneth Blum
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, TX 78701, USA
- Division of Addiction Research & Education, Center for Mental Health & Sports, Exercise and Global Mental Health, Western University Health Sciences, Pomona, CA 91766, USA
- Institute of Psychology, ELTE Eötvös Loránd University, Egyetem tér 1-3, H-1053 Budapest, Hungary
- Department of Psychiatry, School of Medicine, University of Vermont, Burlington, VT 05405, USA
- Department of Psychiatry, Wright State University Boonshoft School of Medicine and Dayton VA Medical Centre, Dayton, OH 45324, USA
- Reward Deficiency Clinics of America, Austin, TX 78701, USA
- Center for Genomics and Applied Gene Technology, Institute of Integrative Omics and applied Biotechnology (IIOAB), Nonakuri, Purba Medinipur, West Bengal 721172, India
- Department of Precision Behavioral Management, Transplicegen Therapeutics, Inc., LLC., Austin, TX 78701, USA
- Department of Molecular Biology and Adelson School of Medicine, Ariel University, Ariel 40700, Israel
| | - Abdalla Bowirrat
- Department of Molecular Biology and Adelson School of Medicine, Ariel University, Ariel 40700, Israel
| | - Catherine A. Dennen
- Department of Family Medicine, Jefferson Health Northeast, Philadelphia, PA 19107, USA
| | - Eric R. Braverman
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, TX 78701, USA
| | - David Baron
- Division of Addiction Research & Education, Center for Mental Health & Sports, Exercise and Global Mental Health, Western University Health Sciences, Pomona, CA 91766, USA
| | | | - John Giordano
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, TX 78701, USA
- Ketamine Infusion Clinic of South Florida, Pompano Beach, FL 33062, USA
| | - Ashim Gupta
- Future Biologics, Lawrenceville, GA 30043, USA
| | - Bernard W. Downs
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, TX 78701, USA
| | - Debasis Bagchi
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, TX 78701, USA
- Department of Pharmaceutical Sciences, Southern University College of Pharmacy, Houston, TX 77004, USA
| | - Debmalya Barh
- Center for Genomics and Applied Gene Technology, Institute of Integrative Omics and applied Biotechnology (IIOAB), Nonakuri, Purba Medinipur, West Bengal 721172, India
- Department of Genetics, Ecology and Evolution, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Igor Elman
- Center for Pain and the Brain (PAIN Group), Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Harvard School of Medicine, Boston, MA 02115, USA
| | - Panayotis K. Thanos
- Behavioral Neuropharmacology and Neuroimaging Laboratory, Clinical Research Institute on Addictions, Department of Pharmacology and Toxicology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA
| | - Rajendra D. Badgaiyan
- Department of Psychiatry, South Texas Veteran Health Care System, Audie L. Murphy Memorial VA Hospital, Long School of Medicine, University of Texas Medical Center, San Antonio, TX 78229, USA
| | - Drew Edwards
- Neurogenesis Project, Jacksonville, FL 32223, USA
| | - Mark S. Gold
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
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Curran M, Holt C, Arciero M, Quinlan J, Cox D, Craig A. Proxy Finnegan Component Scores for Eat, Sleep, Console in a Cohort of Opioid-Exposed Neonates. Hosp Pediatr 2020; 10:1053-1058. [PMID: 33199395 DOI: 10.1542/hpeds.2020-0190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES The Finnegan Neonatal Abstinence Score (FNAS) monitors infants with neonatal abstinence syndrome (NAS), but it has been criticized for being time consuming and subjective. Many institutions have transitioned to a more straightforward screening tool, Eat, Sleep, Console (ESC), an assessment based on 3 simple observations with a focus on maximizing nonpharmacologic therapies. We aimed to compare the sensitivity and specificity of the ESC with that of the FNAS to determine if infants who needed pharmacologic therapy could potentially be missed when assessed by using ESC. METHODS A retrospective cohort study of infants identified by International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision billing codes for NAS. FNAS scores were recorded every 4 hours for the entire hospitalization. ESC proxy scores were created by using components of the FNAS that referenced eating, sleeping, and consoling. Detailed demographic and clinical data were manually extracted regarding opioid exposures and pharmacologic treatment of NAS. RESULTS From 2013 to 2016, 423 infants ≥37 weeks' gestation had a total of 33 115 FNAS scores over 921 days of observation. In total, 287 (68%) were exposed to buprenorphine, 100 (23.7%) were exposed to methadone, and 165 (39%) were pharmacologically treated. The FNAS was 94.8% sensitive and 63.5% specific for pharmacologic treatment, and the ESC proxy variables were 99.4% sensitive and 40.2% specific (P < .01). CONCLUSIONS ESC proxy variables have slightly higher sensitivity compared with FNAS, suggesting that ESC use is unlikely to miss infants requiring treatment who would have been identified by FNAS. Transitioning from FNAS to ESC is not likely to impair the care of infants with NAS.
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Affiliation(s)
- Margaret Curran
- Department of Family Medicine, Maine Medical Center, Portland, Maine; and
| | - Christina Holt
- Department of Family Medicine, Maine Medical Center, Portland, Maine; and
| | - Michael Arciero
- Department of Mathematical Sciences, University of New England, Biddeford, Maine
| | - James Quinlan
- Department of Mathematical Sciences, University of New England, Biddeford, Maine
| | - David Cox
- Department of Pediatrics, The Barbara Bush Children's Hospital and
| | - Alexa Craig
- Department of Pediatrics, The Barbara Bush Children's Hospital and
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Zakerabasali S, Kadivar M, Safdari R, Niakan Kalhori SR, Mokhtaran M, Karbasi Z, Sayarifard A. Development and validation of the Neonatal Abstinence Syndrome Minimum Data Set (NAS-MDS): a systematic review, focus group discussion, and Delphi technique. J Matern Fetal Neonatal Med 2020; 35:617-624. [PMID: 33047642 DOI: 10.1080/14767058.2020.1730319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Neonatal abstinence syndrome (NAS) is a combination of symptoms in infants exposed to any variety of substances in utero. Information systems and registries help to collect information about these patients; however, there is always a deep gap between complete and accurate information to be collected, understood, and applied in the health care system; thus, defining a minimum data sets (MDS) as one of the primarily steps of designing a registry system is essential. The aim of this study was to develop an MDS of the registry for infants with NAS in Iran. METHODS This research is a descriptive cross-sectional study. In this study, three steps were carried out to develop the MDS including systematic review, Delphi technique, and focus group discussion. A systematic review was conducted in relevant databases to identify appropriate related data. In the second phase, a focus group discussion was used to classify the extracted data elements by contributing neonatologists. Finally, data elements were chosen through the decision Delphi technique in two distinct rounds. Collected data were analyzed using SPSS 22 (SPSS Inc., Chicago, IL). RESULTS By reviewing related papers and available NAS registries in other countries, 145 essential data elements were identified. They were classified into two main categories based on the eight experts' opinions including maternal with two sections and infant with two sections. After applying two rounds of Delphi technique, the final data elements for maternal and infant categories were 42 and 31, respectively. Thus, on completion of the survey, 73 data elements were approved. CONCLUSION The proposed MDS for NAS can help to store an accurate and comprehensive data, document medical records, integrate them with other information systems and registries, and communicate with other healthcare providers and healthcare centers. This MDS can contribute to the provision of high-quality care and better clinical decisions.
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Affiliation(s)
- Somayyeh Zakerabasali
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Maliheh Kadivar
- Department of Pediatrics, Division of Neonatology, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Safdari
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Sharareh R Niakan Kalhori
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Zahra Karbasi
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Azadeh Sayarifard
- Community Based Participatory Research Center, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
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Listos J, Łupina M, Talarek S, Mazur A, Orzelska-Górka J, Kotlińska J. The Mechanisms Involved in Morphine Addiction: An Overview. Int J Mol Sci 2019; 20:ijms20174302. [PMID: 31484312 PMCID: PMC6747116 DOI: 10.3390/ijms20174302] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/23/2019] [Accepted: 08/29/2019] [Indexed: 12/22/2022] Open
Abstract
Opioid use disorder is classified as a chronic recurrent disease of the central nervous system (CNS) which leads to personality disorders, co-morbidities and premature death. It develops as a result of long-term administration of various abused substances, along with morphine. The pharmacological action of morphine is associated with its stimulation of opioid receptors. Opioid receptors are a group of G protein-coupled receptors and activation of these receptors by ligands induces significant molecular changes inside the cell, such as an inhibition of adenylate cyclase activity, activation of potassium channels and reductions of calcium conductance. Recent data indicate that other signalling pathways also may be involved in morphine activity. Among these are phospholipase C, mitogen-activated kinases (MAP kinases) or β-arrestin. The present review focuses on major mechanisms which currently are considered as essential in morphine activity and dependence and may be important for further studies.
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Affiliation(s)
- Joanna Listos
- Department of Pharmacology and Pharmacodynamics, Medical University of Lublin, Chodzki 4a St., 20-093 Lublin, Poland.
| | - Małgorzata Łupina
- Department of Pharmacology and Pharmacodynamics, Medical University of Lublin, Chodzki 4a St., 20-093 Lublin, Poland.
| | - Sylwia Talarek
- Department of Pharmacology and Pharmacodynamics, Medical University of Lublin, Chodzki 4a St., 20-093 Lublin, Poland.
| | - Antonina Mazur
- Department of Pharmacology and Pharmacodynamics, Medical University of Lublin, Chodzki 4a St., 20-093 Lublin, Poland.
| | - Jolanta Orzelska-Górka
- Department of Pharmacology and Pharmacodynamics, Medical University of Lublin, Chodzki 4a St., 20-093 Lublin, Poland.
| | - Jolanta Kotlińska
- Department of Pharmacology and Pharmacodynamics, Medical University of Lublin, Chodzki 4a St., 20-093 Lublin, Poland.
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Abstract
Neonates exposed prenatally to opioids will often develop a collection of withdrawal signs known as neonatal abstinence syndrome (NAS). The incidence of NAS has substantially increased in recent years placing an increasing burden on the healthcare system. Traditional approaches to assessment and management have relied on symptom-based scoring tools and utilization of slowly decreasing doses of medication, though newer models of care focused on non-pharmacologic interventions and rooming-in have demonstrated promise in reducing length of hospital stay and medication usage. Data on long-term outcomes for both traditional and newer approaches to care of infants with NAS is limited and an important area of future research. This review will examine the history, incidence and pathophysiology of NAS. We will also review diagnostic screening approaches, scoring tools, differing management approaches and conclude with recommendations for continued work to improve the care of infants with NAS.
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Affiliation(s)
- Matthew Grossman
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States.
| | - Adam Berkwitt
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States
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Abstract
Use of both licit and illicit drugs can lead to a range of medical, psychiatric and social problems, and the situation becomes further complicated if the user is pregnant. Prescribed and non-prescribed substances can affect a pregnancy, and substances are seldom used in isolation. In this review we focus on users of illicit drugs (including prescribed drugs used illicitly) during pregnancy and describe some of the issues in managing such cases. We consider the impact of subtance use on the foetus, the mother and the newborn child, and highlight the importance of multidisciplinary working in this area. Space precludes a detailed account of the issues surrounding the use of legal substances such as alcohol and tobacco during pregnancy, but we note their significant impact in this group.
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Opioid Utilization by Pregnant Women with Sickle Cell Disease and the Risk of Neonatal Abstinence Syndrome. J Natl Med Assoc 2017; 110:163-168. [PMID: 29580450 DOI: 10.1016/j.jnma.2017.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 03/28/2017] [Accepted: 04/04/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pregnant women with sickle cell disease (SCD) are at increased risk of maternal and fetal complications. There are limited data on the outcome of the treatment of VOCs with opioids in relation to neonatal complications during pregnancy. METHODS This is a retrospective cohort study of women with SCD from January 1999 to December 2008. Women with SCD were identified by ICD-9 codes and matched 2:1 to a control group of women on methadone for opioid dependence. The primary outcome was the rate of neonatal abstinence syndrome (NAS). Secondary outcomes included the mean NAS score prior to treatment and the length of treatment. Statistical analysis was performed using SPSS. RESULTS Twenty-one women with SCD who delivered a total of 23 neonates were included. The rate of NAS among infants born to women with SCD who were treated with opioids at any time was 22% compared to 54% in the methadone controls (p = .010). The rate of NAS was 27% among infants born to women taking opioids daily compared to 54% in the methadone control group (p = .062). CONCLUSIONS Neonates born to women with SCD who are treated with daily opioids are at a similar risk for developing NAS as those born to mothers on methadone for opioid dependence. Neonates born to women with SCD treated with episodic opioids are at a significantly lower risk for developing NAS than those born to women on methadone for opioid dependence.
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Konijnenberg C, Sarfi M, Melinder A. Mother-child interaction and cognitive development in children prenatally exposed to methadone or buprenorphine. Early Hum Dev 2016; 101:91-7. [PMID: 27614330 DOI: 10.1016/j.earlhumdev.2016.08.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/04/2016] [Accepted: 08/28/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To assess the influence of mother-child interaction on children's cognitive development in a group of children prenatally exposed to methadone or buprenorphine. STUDY DESIGN The study is part of a prospective longitudinal project investigating the development of children born to women in opioid maintenance therapy (OMT). The sample includes 67 children born between 2005 and 2007, 35 of which prenatally exposed to either methadone or buprenorphine and 32 non-exposed comparison children. RESULTS Both groups scored within the normal range of development. However, the OMT group scored significantly lower on measures of cognitive development and mother-child interaction compared to the comparison group. Cognitive development was found to be affected by both group status, F(1,54)=5.65, p=0.02, η(2)=0.10 and mother-child interaction F(1,54)=5.26, p=0.03, η(2)=0.09. Behavioral inhibition (statue), sensorimotor function (imitating hand positions), and short-term memory (sentences) was influenced by group status while narrative memory and vocabulary were found to be more influenced by mother-child interaction. CONCLUSIONS Different risk factors may influence different cognitive functions in children of women in OMT. Specifically, language-related cognitive skills may be more related to mother-child interaction while performance in higher cognitive functions requiring precise control over sensorimotor responses may be more sensitive to other factors such as prenatal OMT exposure, genetics, and/or prenatal exposure to other substances.
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Affiliation(s)
- Carolien Konijnenberg
- The Cognitive Developmental Research Unit, Department of Psychology, University of Oslo, Norway.
| | - Monica Sarfi
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Annika Melinder
- The Cognitive Developmental Research Unit, Department of Psychology, University of Oslo, Norway
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Jones HE, Fielder A. Neonatal abstinence syndrome: Historical perspective, current focus, future directions. Prev Med 2015; 80:12-7. [PMID: 26232620 DOI: 10.1016/j.ypmed.2015.07.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 07/21/2015] [Accepted: 07/21/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) occurs following prenatal opioid exposure. It is characterized by signs and symptoms indicating central nervous system hyperirritability and autonomic nervous system, gastrointestinal tract, and respiratory system dysfunction. OBJECTIVE This article: (1) briefly reviews NAS history, including initial identification, assessment, and treatment efforts; (2) summarizes the current status of and current issues surrounding recent NAS assessment and treatment, and (3) details future directions in NAS conceptualization, measurement, and treatment. RESULTS Mortality rate estimates in neonates treated for NAS exceeded 33%, and surpassed 90% for un-treated infants during the late-1800s until the mid-1900s. The focus of both assessment and treatment over the past 50years is predominantly due to two forces. First, methadone pharmacotherapy for "heroin addiction" led to women in methadone maintenance programs who were, or became pregnant. The second was defining NAS and developing a measure of neonatal withdrawal, the Neonatal Abstinence Scoring System (NASS). Various NAS treatment protocols were based on the NASS as well as other NAS measures. CONCLUSIONS Future research must focus on psychometrically sound screening and assessment measures of neonatal opioid withdrawal for premature, term and older infants, measuring and treating possible withdrawal from non-opioids, particularly benzodiazepines, integrated non-pharmacological treatment of NAS, weight-based versus symptom-based treatment of NAS, and second-line treatment for NAS.
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Affiliation(s)
- Hendrée E Jones
- UNC Horizons and Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA; Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA.
| | - Andrea Fielder
- School of Nursing and Midwifery, Sansom Institute, University of South Australia, Adelaide, SA 5001, Australia
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Provenza N, Calpena AC, Mallandrich M, Pueyo B, Clares B. Design of pediatric oral formulations with a low proportion of methadone or phenobarbital for the treatment of neonatal abstinence syndrome. Pharm Dev Technol 2015; 21:755-62. [PMID: 26155877 DOI: 10.3109/10837450.2015.1055765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Elaboration of oral liquid formulations is the best alternative when no marketed forms are available for pediatrics. OBJECTIVE The development, characterization and stability evaluation of methadone (MI, MII, MIII) and phenobarbital (PI, PII) can be used for the treatment of neonatal abstinence syndrome (NAS). MATERIAL AND METHODS A standard operating procedure was established and parameters such as appearance, pH, rheological behavior and drug content were evaluated at three temperatures for 90 days. RESULTS AND DISCUSSION Changes in color of phenobarbital made necessary the storage below 25 °C. pH did not change in methadone solutions and was able to maintain phenobarbital solubilized. Degradation data at 4 °C fitted to Plateau equation followed by one phase decay. MI was stable for 60 days at the three temperatures; MII for 90 days at 4 and 25 °C and 60 days at 40 °C; MIII for 60 days at 4 °C, 15 days at 25 °C and 7 days at 4 °C. PI was stable for 60 days at 4 °C and 30 days at 25 °C. PII was stable for 7 days at 4 and 25 °C. All solutions met microbial specifications. CONCLUSION A correct dosage for the treatment of NAS was guaranteed.
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Affiliation(s)
- Nora Provenza
- a Pharmacokinetics and Biopharmaceutics Unit , School of Pharmacy, University of Barcelona , Barcelona , Spain and
| | - Ana C Calpena
- a Pharmacokinetics and Biopharmaceutics Unit , School of Pharmacy, University of Barcelona , Barcelona , Spain and
| | - Mireia Mallandrich
- a Pharmacokinetics and Biopharmaceutics Unit , School of Pharmacy, University of Barcelona , Barcelona , Spain and
| | - Blanca Pueyo
- a Pharmacokinetics and Biopharmaceutics Unit , School of Pharmacy, University of Barcelona , Barcelona , Spain and
| | - Beatriz Clares
- b Department of Pharmacy and Pharmaceutical Technology , School of Pharmacy, University of Granada , Granada , Spain
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Bada HS, Sithisarn T, Gibson J, Garlitz K, Caldwell R, Capilouto G, Li Y, Leggas M, Breheny P. Morphine versus clonidine for neonatal abstinence syndrome. Pediatrics 2015; 135:e383-91. [PMID: 25624389 DOI: 10.1542/peds.2014-2377] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The study goal was to determine whether clonidine treatment of neonatal abstinence syndrome (NAS) would result in a better neurobehavioral performance compared with morphine. METHODS This pilot study prospectively enrolled infants ≥ 35 weeks' gestational age admitted for treatment of NAS. After informed consent was obtained, infants were randomized to receive morphine (0.4 mg/kg per day) or clonidine (5 μg/kg per day) divided into 8 doses. A 25% dose escalation every 24 hours was possible per protocol (maximum of 1 mg/kg per day for morphine and 12 μg/kg per day for clonidine). After control of symptoms, the dose was tapered by 10% every other day. Clinical staff monitored infants by using Finnegan scoring. Masked research staff administered the NICU Network Neurobehavioral Scale (NNNS) at 1 week and at 2 to 4 weeks after initiation of treatment and the Bayley Scales III, and Preschool Language Scale IV, at 1-year adjusted age. Analyses included descriptive statistics, repeated measures analysis of variance, and Wilcoxon tests. RESULTS Infants treated with morphine (n = 15) versus clonidine (n = 16) did not differ in birth weight or age at treatment. Treatment duration was significantly longer for morphine (median 39 days) than for clonidine (median 28 days; P = .02). NNNS summary scores improved significantly with clonidine but not with morphine. On subsequent assessment, those receiving clonidine had lower height of arousal and excitability (P < .05). One-year motor, cognitive, and language scores did not differ between groups. CONCLUSIONS Clonidine may be a favorable alternative to morphine as a single-drug therapy for NAS. A multicenter randomized trial is warranted.
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Affiliation(s)
| | | | - Julia Gibson
- Department of Pharmacy, Kentucky Children's Hospital, Lexington, Kentucky; and
| | - Karen Garlitz
- Department of Pharmacy, Kentucky Children's Hospital, Lexington, Kentucky; and
| | | | | | - Yinglei Li
- Statistics, College of Arts and Sciences and
| | - Markos Leggas
- Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Patrick Breheny
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa
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The right tool at the right time: examining the evidence surrounding measurement of neonatal abstinence syndrome. Adv Neonatal Care 2014; 14:181-6. [PMID: 24858668 DOI: 10.1097/anc.0000000000000095] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Opioid use in pregnant women has increased over the last decade. Following birth, infants with in utero exposure demonstrate signs and symptoms of withdrawal known as the neonatal abstinence syndrome (NAS). Infants express a spectrum of disease, with most requiring the administration of pharmacologic therapy to ensure proper growth and development. Treatment often involves prolonged hospitalization. There is a general lack of high-quality clinical trial data to guide optimal therapy, and significant heterogeneity in treatment approaches. Emerging trends in the treatment of infants with NAS include the use of sublingual buprenorphine, transition to outpatient therapy, and pharmacogenetic risk stratification.
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Affiliation(s)
- Walter K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, 1170 Main Building, 132 South 10th Street, Philadelphia, PA 19107, USA.
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Murphy-Oikonen J, Montelpare WJ, Bertoldo L, Southon S, Persichino N. The impact of a clinical practice guideline on infants with neonatal abstinence syndrome. ACTA ACUST UNITED AC 2012. [DOI: 10.12968/bjom.2012.20.7.493] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Larry Bertoldo
- Larry Bertoldo Clinical Practice Lead, Thunder Bay Regional Health Sciences Centre
| | - Sarah Southon
- Sarah Southon Associate Faculty, Faculty of Nursing, University of Alberta
| | - Nancy Persichino
- Nancy Persichino Director of Women and Children`s Program, Thunder Bay Regional Health Sciences Centre
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Raith W, Kutschera J, Müller W, Urlesberger B. Active Ear Acupuncture Points in Neonates with Neonatal Abstinence Syndrome (NAS). THE AMERICAN JOURNAL OF CHINESE MEDICINE 2012; 39:29-37. [DOI: 10.1142/s0192415x11008622] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of the study was to determine the presence of acupuncture ear points in neonates with Neonatal Abstinence Syndrome (NAS). NAS occurs in the first days of life in neonates whose mothers have a history of drug abuse, and may also occur in neonates whose mothers are currently following substitution therapy. The patients are neonates with NAS admitted over one year to the Division of Neonatology at the University Hospital Graz. The examination took place on the third day after delivery (mean value 70.3 hours) and was performed by a neuronal pen (PS 3 © Silberbauer, Vienna, Austria). An integrated sound and optical signal detected the active ear points that were then placed on an ear map. We investigated six neonates (four male, two female). All investigated neonates showed the presence of active ear acupuncture points. The psychovegetative rim was the most common organic area of the children, following by a few organic points. This corresponds with the results found in healthy neonates. In all neonates with NAS, we found the presence of psychic ear points. The identified psychic ear points are the frustration-point, R-point and the psychotropic area nasal from the incisura intertragica. In all neonates with NAS, active organic and psychic ear points were detectable in both ears. In the future, it could be possible to use active ear points for diagnostic and therapeutic purposes.
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Affiliation(s)
- Wolfgang Raith
- Research Group for Paediatric Traditional Chinese Medicine, Medical University of Graz, Austria
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
| | - Jörg Kutschera
- Research Group for Paediatric Traditional Chinese Medicine, Medical University of Graz, Austria
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
| | - Wilhelm Müller
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
| | - Berndt Urlesberger
- Research Group for Paediatric Traditional Chinese Medicine, Medical University of Graz, Austria
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria
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Ineffective morphine treatment regimen for the control of Neonatal Abstinence Syndrome in buprenorphine- and methadone-exposed infants. J Dev Orig Health Dis 2012; 3:262-70. [DOI: 10.1017/s2040174412000190] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This study aimed to determine if morphine is effective in ameliorating Neonatal Abstinence Syndrome (NAS) symptoms to non-opioid-exposed control levels in methadone- and buprenorphine-exposed infants. A prospective, non-randomized comparison study with flexible dosing was undertaken in a large teaching maternity hospital in Australia. Twenty-five infants in the groups of buprenorphine-, methadone- and control non-opioid-exposed infants were compared (totaln= 75 infants). Oral morphine sulphate (1 mg/ml) was administered every 4 h to opioid agonist-exposed infants. Modified Finnegan Withdrawal Scale (MFWS) scores determined dosing: score of 8–10: 0.5 mg/kg/day, 11–13: 0.7 mg/kg/day and 14+: 0.9 mg/kg/day. Withdrawal score, amount of morphine administered and length of hospital stay, were used to assess NAS over a 4-week follow-up period. No controls achieved a score higher than 7 on the MFWS. There was no significant difference in the percentage of infants requiring treatment between methadone (60%) and buprenorphine (48%) infants. For treated infants, significantly (P< 0.01) more morphine was administered to methadone (40.07 ± 3.95 mg) compared with buprenorphine infants (22.77 ± 4.29 mg) to attempt to control NAS. Following treatment initiation, significantly more (P< 0.01) methadone (87%) compared with buprenorphine infants (42%) continued to exceed scoring thresholds for morphine treatment requirement, and non-opioid-exposed control infant scores. For treated infants, there was no significant difference in length of hospital stay between methadone and buprenorphine infants. Morphine treatment was not entirely effective in ameliorating NAS to non-opioid-exposed control symptom levels in methadone or buprenorphine infants. The regimen may be less effective in methadone compared with buprenorphine infants.
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Abstract
Maternal use of certain drugs during pregnancy can result in transient neonatal signs consistent with withdrawal or acute toxicity or cause sustained signs consistent with a lasting drug effect. In addition, hospitalized infants who are treated with opioids or benzodiazepines to provide analgesia or sedation may be at risk for manifesting signs of withdrawal. This statement updates information about the clinical presentation of infants exposed to intrauterine drugs and the therapeutic options for treatment of withdrawal and is expanded to include evidence-based approaches to the management of the hospitalized infant who requires weaning from analgesics or sedatives.
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Pharmacological treatment of neonatal opiate withdrawal: between the devil and the deep blue sea. Int J Pediatr 2011; 2011:935631. [PMID: 21760818 PMCID: PMC3133472 DOI: 10.1155/2011/935631] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 02/18/2011] [Accepted: 03/28/2011] [Indexed: 11/17/2022] Open
Abstract
Illicit drug use with opiates in pregnancy is a major global health issue with neonatal withdrawal being a common complication. Morphine is the main pharmacological agent administered for the treatment of neonatal withdrawal. In the past, morphine has been considered by and large inert in terms of its long-term effects on the central nervous system. However, recent animal and clinical studies have demonstrated that opiates exhibit significant effects on the growing brain. This includes direct dose-dependent effects on reduction in brain size and weight, protein, DNA, RNA, and neurotransmitters—possibly as a direct consequence of a number of opiate-mediated systems that influence neural cell differentiation, proliferation, and apoptosis. At this stage, we are stuck between the devil and the deep blue sea. There are no real alternatives to pharmacological treatment with opiates and other drugs for neonatal opiate withdrawal and opiate addiction in pregnant women. However, pending further rigorous studies examining the potential harmful effects of opiate exposure in utero and the perinatal period, prolonged use of these agents in the neonatal period should be used judiciously, with caution, and avoided where possible.
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Kraft WK, Dysart K, Greenspan JS, Gibson E, Kaltenbach K, Ehrlich ME. Revised dose schema of sublingual buprenorphine in the treatment of the neonatal opioid abstinence syndrome. Addiction 2011; 106:574-80. [PMID: 20925688 PMCID: PMC3022999 DOI: 10.1111/j.1360-0443.2010.03170.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS More than half of infants exposed to opioids in utero develop neonatal abstinence syndrome (NAS) of severity to require pharmacological therapy. Current treatments are associated with prolonged hospitalization. We sought to optimize the dose of sublingual buprenorphine in the treatment of NAS. DESIGN Randomized, Phase 1, open-label, active-control clinical trial comparing sublingual buprenorphine to oral morphine. SETTING Large, urban, tertiary care hospital. PARTICIPANTS Twenty-four term infants requiring pharmacological treatment for NAS. MEASUREMENTS Outcomes were neonatal safety, length of treatment and length of hospitalization. FINDINGS Sublingual buprenorphine was safe and effective. Infants treated with buprenorphine had a 23-day length of treatment compared to 38 days for those treated with morphine (P = 0.01), representing a 40% reduction. Length of hospital stay in the buprenorphine group was reduced 24%, from 42 to 32 days (P = 0.05). CONCLUSIONS Sublingual buprenorphine was safe in NAS, with a substantial efficacy advantage over standard of care therapy with oral morphine.
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Affiliation(s)
- Walter K. Kraft
- Department of Pharmacology and Experimental Therapeutics, Jefferson Medical College, Philadelphia
| | - Kevin Dysart
- Department of Pediatrics, Jefferson Medical College, Philadelphia
,A.I. DuPont Hospital for Children, Wilmington, DE
| | - Jay S. Greenspan
- Department of Pediatrics, Jefferson Medical College, Philadelphia
,A.I. DuPont Hospital for Children, Wilmington, DE
| | - Eric Gibson
- Department of Pediatrics, Jefferson Medical College, Philadelphia
,A.I. DuPont Hospital for Children, Wilmington, DE
| | - Karol Kaltenbach
- Department of Pediatrics, Jefferson Medical College, Philadelphia
| | - Michelle E. Ehrlich
- Mt. Sinai School of Medicine, New York, NY, Departments of Pediatrics and Neurology
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Hartenstein S, Proquitté H, Bauer S, Bamberg C, Roehr CC. Neonatal abstinence syndrome (NAS) after intrauterine exposure to tramadol. J Perinat Med 2010; 38:695-6. [PMID: 20707626 DOI: 10.1515/jpm.2010.102] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Papaseit E, Corrales E, Stramesi C, Vall O, Palomeque A, Garcia-Algar O. Postnatal methadone withdrawal syndrome: hair analysis for detecting chronic exposure. Acta Paediatr 2010; 99:162-3. [PMID: 19839962 DOI: 10.1111/j.1651-2227.2009.01555.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Saiki T, Lee S, Hannam S, Greenough A. Neonatal abstinence syndrome--postnatal ward versus neonatal unit management. Eur J Pediatr 2010; 169:95-8. [PMID: 19440732 DOI: 10.1007/s00431-009-0994-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 04/30/2009] [Indexed: 11/24/2022]
Abstract
AIM The aim of this cohort study was to test the hypothesis that caring for infants with neonatal abstinence syndrome (NAS) with their mothers on the postnatal ward rather than admit them to the neonatal unit would reduce treatment duration and length of hospital stay. RESULTS The outcomes of infants with NAS cared for in 2002-2005 (Group A, n = 42) and 2006-2007 (Group B, n = 18) were compared. Group A infants were admitted to the neonatal unit for assessment and treatment as necessary, but Group B infants remained on the postnatal ward with their mother. Sixty infants (median gestational age 39, range 26-42 weeks) were included in the study. The proportion of infants in Group B compared to Group A requiring treatment for NAS was lower (45% versus 11%, p = 0.012) and the durations of treatment (mean 12.7 versus 7.3 days, p = 0.05) and hospital stay (mean 19.8 versus 15.9 days, p = 0.012) were shorter in Group B. No infant in either group was readmitted within the next 2 months. CONCLUSIONS These results suggest caring for infants with NAS on the postnatal ward rather than the neonatal unit reduces the need for treatment and duration of hospital stay.
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Affiliation(s)
- Tolulope Saiki
- Division of Asthma, Allergy and Lung Biology, King's College London, MRC, Asthma Centre, King's College Hospital, Denmark Hill, London SE5 9RS, UK
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Burns L, Mattick RP. Using population data to examine the prevalence and correlates of neonatal abstinence syndrome. Drug Alcohol Rev 2009; 26:487-92. [PMID: 17701511 DOI: 10.1080/09595230701494416] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The objective of this study was to determine the population prevalence and correlates of neonatal abstinence syndrome among neonates born to women on methadone, using a cross-sectional analysis of linked population health data. A total of 2941 live births to women actively on methadone at delivery were analysed over an 11-year period (1992 - 2002). Of these births, 796 neonates (27%) were diagnosed with an International Classification of Diseases - 9CM (ICD-9CM) or International Classification of Diseases ICD - 10AM (ICD-10AM) diagnosis related to neonatal withdrawal from exposure to opiates in utero (NAS). There were significant differences found between mothers whose neonates did and did not receive an International Classification of Diseases NAS-related diagnosis. Mothers of neonates with a NAS-related diagnosis had a higher number of previous pregnancies, were more likely to be indigenous, to smoke more heavily and were more likely to present for delivery unbooked. Neonates diagnosed with NAS were admitted to Special Care Nursery more often. NAS is diagnosed less frequently using International Classification of Diseases (ICD) codes than when using clinical scales measuring opiate-related neonatal withdrawal. This suggests that NAS may be under-represented in hospital morbidity databases that use ICD codes to quantify patient throughput and in some circumstances this may result from under-detection of the condition. Future research should therefore seek to determine the validity of NAS recording in hospital morbidity databases reliant on the use ICD codes.
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Affiliation(s)
- Lucy Burns
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.
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Agthe AG, Kim GR, Mathias KB, Hendrix CW, Chavez-Valdez R, Jansson L, Lewis TR, Yaster M, Gauda EB. Clonidine as an adjunct therapy to opioids for neonatal abstinence syndrome: a randomized, controlled trial. Pediatrics 2009; 123:e849-56. [PMID: 19398463 PMCID: PMC2746902 DOI: 10.1542/peds.2008-0978] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine if oral clonidine would reduce the duration of opioid detoxification for neonatal abstinence syndrome. METHODS Infants with intrauterine exposure to methadone or heroin and neonatal abstinence syndrome (2 consecutive modified Finnegan scores of > or =9) were enrolled at 2 hospitals during 2002-2005 and followed until final hospital discharge. All enrolled infants (80) received oral diluted tincture of opium according to a standardized algorithm and were randomly assigned to receive oral clonidine (1 microg/kg every 4 hours) (40 infants) or placebo (40 infants). Primary outcome was duration of opioid therapy. Secondary outcomes included the amount of opium required to control symptoms, number of treatment failures, and differences in blood pressure, heart rate, and oxygen saturation. RESULTS The median length of therapy was 27% shorter in the clonidine group (11 [95% confidence interval: 8-15 days]) than in the placebo group (15 days [95% confidence interval: 12-17 days]). In the clonidine group, 7 infants required restarting opium after initial discontinuation versus none in the placebo group, with the total length of treatment/observation remaining significantly less in the clonidine group. Higher dosages of opium were required by 40% of the infants in the placebo group versus 20% in the clonidine group. Treatment failures occurred in 12.5% of the infants in the placebo group versus none in the clonidine group. Hypertension, hypotension, bradycardia, or desaturations did not occur in either group. Three infants in the clonidine group died as a result of myocarditis, sudden infant death syndrome, and homicide, all after hospital discharge and before 6 months of age. CONCLUSIONS In this randomized, double-blind trial, adding clonidine to standard opioid therapy for detoxification from in utero exposure to methadone or heroin reduced the duration of pharmacotherapy for neonatal abstinence without causing short-term adverse cardiovascular outcomes. A larger trial is indicated to determine long-term safety.
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Affiliation(s)
- Alexander G. Agthe
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland,Department of Pediatrics, University of Maryland Medical Center, Baltimore, Maryland
| | - George R. Kim
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Kay B. Mathias
- Center for Neonatal Transitional Care, Mt Washington Pediatric Hospital, Baltimore, Maryland
| | - Craig W. Hendrix
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Raul Chavez-Valdez
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Lauren Jansson
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Tamorah R. Lewis
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Myron Yaster
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland,Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Estelle B. Gauda
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland,Center for Neonatal Transitional Care, Mt Washington Pediatric Hospital, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
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Jansson LM, Velez M, Harrow C. The opioid-exposed newborn: assessment and pharmacologic management. J Opioid Manag 2009; 5:47-55. [PMID: 19344048 PMCID: PMC2729086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The infant exposed to opioids in utero frequently presents a challenge to the neonatal care provider in the assessment and treatment of symptoms of Neonatal Abstinence Syndrome (NAS) after birth. This review is intended to provide the healthcare professional with a brief review of current evidence and practical guidelines for optimal evaluation and pharmacologic management of the opioid-exposed newborn.
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Affiliation(s)
- Lauren M Jansson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
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27
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Affiliation(s)
- Lauren M Jansson
- The Center for Addiction and Pregnancy, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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Kraft WK, Gibson E, Dysart K, Damle VS, LaRusso JL, Greenspan JS, Moody DE, Kaltenbach K, Ehrlich ME. Sublingual buprenorphine for treatment of neonatal abstinence syndrome: a randomized trial. Pediatrics 2008; 122:e601-7. [PMID: 18694901 PMCID: PMC2574639 DOI: 10.1542/peds.2008-0571] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In utero exposure to drugs of abuse can lead to neonatal abstinence syndrome, a condition that is associated with prolonged hospitalization. Buprenorphine is a partial mu-opioid agonist used for treatment of adult detoxification and maintenance but has never been administered to neonates with opioid abstinence syndrome. The primary objective of this study was to demonstrate the feasibility and, to the extent possible in this size of study, the safety of sublingual buprenorphine in the treatment of neonatal abstinence syndrome. Secondary goals were to evaluate efficacy relative to standard therapy and to characterize buprenorphine pharmacokinetics when sublingually administered. METHODS We conducted a randomized, open-label, active-control study of sublingual buprenorphine for the treatment of opiate withdrawal. Thirteen term infants were allocated to receive sublingual buprenorphine 13.2 to 39.0 mug/kg per day administered in 3 divided doses and 13 to receive standard-of-care oral neonatal opium solution. Dose decisions were made by using a modified Finnegan scoring system. RESULTS Sublingual buprenorphine was largely effective in controlling neonatal abstinence syndrome. Greater than 98% of plasma concentrations ranged from undetectable to approximately 0.60 ng/mL, which is less than needed to control abstinence symptoms in adults. The ratio of buprenorphine to norbuprenorphine was larger than that seen in adults, suggesting a relative impairment of N-dealkylation. Three infants who received buprenorphine and 1 infant who received standard of care reached protocol-specified maximum doses and required adjuvant therapy with phenobarbital. The mean length of treatment for those in the neonatal-opium-solution group was 32 compared with 22 days for the buprenorphine group. The mean length of stay for the neonatal-opium-solution group was 38 days compared with 27 days for those in the buprenorphine group. Treatment with buprenorphine was well tolerated. CONCLUSIONS Buprenorphine administered via the sublingual route is feasible and apparently safe and may represent a novel treatment for neonatal abstinence syndrome.
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Affiliation(s)
- Walter K. Kraft
- Department of Pharmacology and Experimental Therapeutics, Jefferson Medical College, Philadelphia, PA 19107
| | - Eric Gibson
- Department of Pediatrics, Jefferson Medical College, Philadelphia, PA 19107,A.I. DuPont Hospital for Children, Wilmington, DE
| | - Kevin Dysart
- Department of Pediatrics, Jefferson Medical College, Philadelphia, PA 19107,A.I. DuPont Hospital for Children, Wilmington, DE
| | - Vidula S. Damle
- Department of Pediatrics, Jefferson Medical College, Philadelphia, PA 19107,A.I. DuPont Hospital for Children, Wilmington, DE
| | - Jennifer L. LaRusso
- Department of Pharmacology and Experimental Therapeutics, Jefferson Medical College, Philadelphia, PA 19107
| | - Jay S. Greenspan
- Department of Pediatrics, Jefferson Medical College, Philadelphia, PA 19107,A.I. DuPont Hospital for Children, Wilmington, DE
| | - David E. Moody
- University of Utah, Center for Human Toxicology, Salt Lake City, UT
| | - Karol Kaltenbach
- Department of Pediatrics, Jefferson Medical College, Philadelphia, PA 19107
| | - Michelle E. Ehrlich
- Department of Neurology, Jefferson Medical College, Philadelphia, PA 19107,Department of Pediatrics, Jefferson Medical College, Philadelphia, PA 19107,A.I. DuPont Hospital for Children, Wilmington, DE
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Mazurier E, Cambonie G, Barbotte E, Grare A, Pinzani V, Picaud JC. Comparison of chlorpromazine versus morphine hydrochloride for treatment of neonatal abstinence syndrome. Acta Paediatr 2008; 97:1358-61. [PMID: 18644009 DOI: 10.1111/j.1651-2227.2008.00918.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To compare the duration of treatment for neonatal abstinence syndrome (NAS) using chlorpromazine versus morphine hydrochloride. METHODS We compared two case series of term infants with NAS treated with either morphine hydrochloride (MH) or chlorpromazine (CP). Seventeen infants were treated with MH from 1998 to 1999, and 20 infants were managed with CP from 2000 to 2001. The duration of treatment was compared, and multivariate analysis was used to identify independent risk factors related to the duration of treatment. RESULTS Characteristics of the mothers (duration of drug addiction, abuse of other substances) and infants (birth weight, proportion breastfed) were similar in the two groups. The mean duration of CP treatment was 6 days (range 3.5-9 days), significantly fewer days than with MH treatment, which was 16 days (range 10-21 days; p < 0.001). There were fewer hospitalization days (11 days; range 9-14 days) for CP treatment compared with MH-treated infants (18 days; range 16-25 days). Treatment with CP was independently associated with shorter hospitalization time. CONCLUSION CP appears to shorten the duration of NAS compared with MH. Larger prospective randomized trials are needed to confirm our findings.
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Affiliation(s)
- E Mazurier
- CHU de Montpellier, Service neonatologie, Hopital Arnaud De Villeneuve, Montpellier, France.
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Abstract
The management of the infant exposed to drugs in utero poses significant challenges. Symptoms and signs of neonatal abstinence syndrome (NAS) are non-specific but most commonly associated with withdrawal from maternal opioids. A high index of suspicion is required when presented with an infant who could be manifesting symptoms of NAS. In the absence of a reliable history of maternal drug exposure, analysis of neonatal meconium or urine may be indicated. Approximately 90% of infants exposed to opioids will exhibit signs of NAS, although a smaller proportion will require pharmacological treatment. Although few studies have evaluated the advantages of different therapeutic agents and strategies, opioid withdrawal is best treated initially with opioid medication. Supportive care of the infant should include assessment of the adequacy of feeding, evaluation of social circumstances (particularly child protection issues) and surveillance for transmission of viral infection.
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Ebner N, Rohrmeister K, Winklbaur B, Baewert A, Jagsch R, Peternell A, Thau K, Fischer G. Management of neonatal abstinence syndrome in neonates born to opioid maintained women. Drug Alcohol Depend 2007; 87:131-8. [PMID: 17000060 DOI: 10.1016/j.drugalcdep.2006.08.024] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Revised: 08/07/2006] [Accepted: 08/07/2006] [Indexed: 10/24/2022]
Abstract
Neonates born to opioid-maintained mothers are at risk of developing neonatal abstinence syndrome (NAS), which often requires pharmacological treatment. This study examined the effect of opioid maintenance treatment on the incidence and timing of NAS, and compared two different NAS treatments (phenobarbital versus morphine hydrochloride). Fifty-three neonates born to opioid-maintained mothers were included in this study. The mothers received methadone (n=22), slow-release oral morphine (n=17) or buprenorphine (n=14) throughout pregnancy. Irrespective of maintenance treatment, all neonates showed APGAR scores comparable to infants of non-opioid dependent mothers. No difference was found between the three maintenance groups regarding neonatal weight, length or head circumference. Sixty percent (n=32) of neonates required treatment for NAS [68% in the methadone-maintained group (n=15), 82% in the morphine-maintained group (n=14), and 21% in the buprenorphine-maintained group (n=3)]. The mean duration from birth to requirement of NAS treatment was 33 h for the morphine-maintained group, 34 h for the buprenorphine-maintained group and 58 h for the methadone-maintained group. In neonates requiring NAS treatment, those receiving morphine required a significantly shorter mean duration of treatment (9.9 days) versus those treated with phenobarbital (17.7 days). Results suggest that morphine hydrochloride is preferable for neonates suffering NAS due to opioid withdrawal.
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Affiliation(s)
- Nina Ebner
- Department of Psychiatry, Medical University Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Miles J, Sugumar K, Macrory F, Sims DG, D'Souza SW. Methadone-exposed newborn infants: outcome after alterations to a service for mothers and infants. Child Care Health Dev 2007; 33:206-12. [PMID: 17291325 DOI: 10.1111/j.1365-2214.2006.00635.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the impact of a shared care approach in clinical management with a drug liaison midwife (DLM) service for mothers and infants established in 1995-1996 in an inner city area and to address the problem of congenital abnormality and microcephaly with fetal drug exposure. METHODS Descriptive analysis of data in live births of women enrolled in a methadone maintenance programme in 1991-1994 (n = 78) and 1997-2001 (n = 98), including time spent in hospital, treatment for neonatal abstinence syndrome (NAS), admission to the neonatal medical unit (NMU) and follow-up for child health checks. RESULTS In 1997-2001 compared with 1991-1994, the mothers used more methadone in the last week of pregnancy (median 40.0 mg/day vs. 21.5 mg/day, P = 0.0006) and there were more preterm deliveries (36% vs. 21%, P = 0.03). The infants spent less time in hospital (median 5 days vs. 28 days, P < 0.0001), a smaller proportion had treatment for NAS (14% vs. 79%, P < 0.0001), and NMU admission was reduced (median 14 days vs. 26 days, P < 0.0003). Neonatal convulsions (P = 0.0001) and jaundice (P < 0.001) occurred less frequently, and more infants were breastfed (P = 0.001). One infant in each study group had a cleft palate and none had microcephaly. Child health checks for 18-24 months showed a favourable outcome in 1997-2001. CONCLUSIONS We altered antenatal care and modified neonatal management, subsequently infants spent less time in hospital and NMU admissions were reduced with less NAS treatment. Congenital abnormalities and microcephaly were not common and as regular child health checks were possible, the impact of the DLM service in shared management merits further investigation, for mother-infant bonding and developmental outcome.
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Affiliation(s)
- J Miles
- University of Manchester, Division of Human Development and Reproductive Health Clinical Academic Group, St Mary's Hospital, Manchester, UK
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Mawhinney S, Ashe RG, Lowry J. Substance abuse in pregnancy: opioid substitution in a northern Ireland maternity unit. THE ULSTER MEDICAL JOURNAL 2006; 75:187-91. [PMID: 16964809 PMCID: PMC1891783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
An increase in illicit drug use in Northern Ireland may well have links to the resolution of political conflict, which started in the mid 1990s. Social issues, heretofore hidden, have emerged into the limelight and may be worsened by paramilitary involvement. Registered addicts in the four Health Board areas have shown an increase from 1997 with the greatest number resident within the Northern Board Area. As the prevalence of heroin use in Northern Ireland increased, the Department of Health and Social Services and Public Safety (DHSSPS) commissioned a report, to recommend the development of substitute prescribing services. A case series of pregnancies was reviewed, within the Northern Board Area, where the mother was taking opioid substitution therapy. This resulted in baseline data of outcome for both mother and baby specific to a Northern Ireland population. The different medications for opioid substitution are also assessed. This information will guide a co-ordinated approach that involves obstetrician, anaesthetist, psychiatrist, midwife and social worker to the care of these high-risk pregnancies. Eighteen pregnancies were identified in the study period. Sixteen of these had viable outcomes. One was a twin pregnancy. Outcome data was therefore available for 17 infants. Information was obtained regarding patients' social and demographic background, drug taking behaviour and substitution regimen. Antenatal and intrapartum care was assessed and infants were followed up to the time of hospital discharge.
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Affiliation(s)
- Sandra Mawhinney
- Department of Obstetrics and Gynaecology Antrim Area Hospital, 45 Bush Road, Antrim BT41 2RL, United Kingdom.
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Fraser JA, Barnes M, Biggs HC, Kain VJ. Caring, chaos and the vulnerable family: experiences in caring for newborns of drug-dependent parents. Int J Nurs Stud 2006; 44:1363-70. [PMID: 16938299 DOI: 10.1016/j.ijnurstu.2006.06.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2006] [Revised: 06/19/2006] [Accepted: 06/27/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Infants exposed to intrauterine drugs present a number of challenging features with which the new mother is faced. They can be irritable, unresponsive, and unpredictable. Available treatments require specialised neonatal care for the first four to six weeks of life; a critical time for the parent-infant attachment relationship to develop. Neonatal nurses have the opportunity to promote this development and ameliorate the effect of other developmental risk factors the baby is likely to experience. OBJECTIVES The aim of this study was to explore neonatal nurses' experiences of providing care to drug-exposed newborns and their parents throughout treatment for neonatal abstinence syndrome (NAS). DESIGN, SETTING AND PARTICIPANTS This study used interpretive methods by conducting group interviews with eight neonatal nurses in each of four Special Care Nursery Units in South-East Queensland, Australia. RESULTS Barriers to promoting the parent-infant attachment relationship were found to be both attitudinal and organisational. These barriers were significant, and were seen to impact negatively on optimal care delivery to this vulnerable population. CONCLUSIONS Unfortunately, the results of this study indicated that management of these babies and their parents is compromised by a range of attitudinal and organisational factors. There is a need to address these barriers to optimise care delivery and improve the way in which neonatal nurses impact on parent-infant relationships.
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Affiliation(s)
- Jennifer A Fraser
- School of Nursing, Queensland University of Technology, Brisbane, Qld., Australia.
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Abstract
AIMS To examine the obstetric and perinatal outcomes for women with a drug-related hospital admission during pregnancy. DESIGN Antenatal and birth admissions to New South Wales (NSW) hospitals from the NSW Inpatient Statistics Collection were linked to birth information from the NSW Midwives Data Collection over a 5-year period (1998-2002). MEASUREMENTS Birth admissions were flagged as positive for drug use where a birth admission or any pregnancy admission for that birth involved an opioid, cannabis or stimulant-related International Classification of Diseases version 10 Australian modification (ICD-10AM) code. FINDINGS A total of 416 834 live births were analysed over a 5-year period (1998-2002). Of these, 1974 pregnancies had an opioid ICD-10AM diagnosis recorded, 552 a stimulant-related ICD-10AM and 2172 a cannabis ICD-10AM diagnosis. Births in each of the drug groups were to women who were younger, had a higher number of previous pregnancies, were indigenous, smoked heavily and were not privately insured. These women also presented later in their pregnancy to antenatal services and were more likely to arrive at hospital unbooked. Neonates born to women in each of the drug groups were more likely to be premature and were admitted to neonatal intensive care and special care nursery more often, with neonates born to women in the opioid group admitted most often. CONCLUSIONS Linked population level administrative data is a powerful method for examining the maternal and neonatal outcomes associated with the use of specific illicit drugs during pregnancy.
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Affiliation(s)
- Lucy Burns
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.
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Abstract
The nursing care of infants experiencing withdrawal from drug abuse through passive exposure is often challenging. These infants are at higher risk for many medical complications in addition to withdrawal itself. Often, infusion nurses play an important role in caring for an infant with drug withdrawal by providing infusion therapy for the infant's compromised medical condition, poor oral intake, and withdrawal symptoms. This article focuses on drug abuse during pregnancy, the withdrawal symptoms it may cause in the infant, ways to recognize an infant experiencing neonatal abstinence syndrome, and available scoring tools and treatment options.
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Siden HB, Collin K. Three patients and their drugs: A parallel case paper on paediatric opiate use and withdrawal. Paediatr Child Health 2005; 10:163-8. [DOI: 10.1093/pch/10.3.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Arlettaz R, Kashiwagi M, Das-Kundu S, Fauchère JC, Lang A, Bucher HU. Methadone maintenance program in pregnancy in a Swiss perinatal center (II): neonatal outcome and social resources. Acta Obstet Gynecol Scand 2005; 84:145-50. [PMID: 15683374 DOI: 10.1111/j.0001-6349.2005.00510.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The aim of the study was to analyze the neonatal impact of a methadone maintenance program in pregnancy, and the social resources of the families involved. METHODS Descriptive analysis of neonatal data in live births after 24 weeks of gestation in pregnant women enrolled in a methadone maintenance program. The data of 86 babies were analyzed. RESULTS Median gestational age was 38 (0)/(7) (31-41) weeks; 21 babies (24%) were premature. Median birthweight was 2662 (1340-4050) g; 27% of babies were growth retarded (<3rd centile), and 13% had microcephaly (<3rd centile). Sixty-two percent developed abstinence syndrome requiring pharmacological treatment for a median 47 days. Child Protective Services (CPS) were involved in 56% of cases, and 42% of newborns required placement outside the mother's home. CONCLUSIONS Babies born to women on methadone had a fourfold higher incidence of prematurity, a ninefold higher incidence of intrauterine growth retardation (IUGR), and a fourfold higher incidence of microcephaly compared with the normal population. Sixty-two percent required pharmacological treatment for abstinence syndrome and 42% required placement.
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Affiliation(s)
- Romaine Arlettaz
- Clinic of Neonatology, Zurich University Hospital, Frauenklinikstrasse 10, CH-8091 Zurich, Switzerland.
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Langenfeld S, Birkenfeld L, Herkenrath P, Müller C, Hellmich M, Theisohn M. Therapy of the neonatal abstinence syndrome with tincture of opium or morphine drops. Drug Alcohol Depend 2005; 77:31-6. [PMID: 15607839 DOI: 10.1016/j.drugalcdep.2004.07.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2004] [Revised: 07/02/2004] [Accepted: 07/16/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treating opioid-addicted women with methadone in pregnancy increased the number of newborns suffering from neonatal abstinence syndrome (NAS). High-pitch crying, insomnia, tremor, myoclonic jerks, vomiting, diarrhoea and poor weight gain were reported symptoms, which were evaluated using the Finnegan (F)-score. Earlier phenobarbital or paregoric had been used to suppress symptoms. We surveyed the administration of pure mu-agonist morphine (MO) in comparison to the alcoholic opioid mixture in tincture of opium (TO). Thirty-three newborns were included in the survey, after informed consent by their parents. RESULTS NAS started 3-5 days after delivery and lasted for 27 or 30 days (mean) in the TO and MO groups, respectively. In either of the tested parameters, we found no significant differences between the two groups (2P < 0.05). The maximum F-score was similar in both groups, but the dose to suppress NAS was higher in the MO group (0.6-0.5 mg/day; total dose 61.6-42.7 mg of morphine). The duration of the therapy was longer in the MO than in the TO group (37.5-32.4 days). On the other hand the weight gain was better in the MO group than in the TO group (25-19 g/day), but was reduced in both groups compared with healthy newborns. CONCLUSIONS Morphine is suitable to treat NAS in a similar manner as tincture of opium, but avoids unwanted effects of the alcoholic extracts with various alkaloids in the tincture of opium and allows better weight gain of the newborns.
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Affiliation(s)
- Stefan Langenfeld
- Children's Hospital, University of Cologne, Joseph Stelzmann Str. 9, Cologne 50931, Germany
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Abstract
The use of illicit substances such as cocaine and heroin during pregnancy is common. Anonymous screening of consecutive urine samples testing positive for pregnancy from a UK inner-city clinic demonstrated that approximately 16% of the women had taken one or more illicit substances (Sherwood et al, 1999). The prevalence of drug misuse in the USA appears to be even higher: prospective screening of newborns in a high-risk urban population revealed that 44% of 3010 babies tested positive for opiates, cocaine or cannabis (Ostrea et al, 1992). The aim of this editorial is to emphasise the importance of this topic by describing the unfavourable effects illicit substances can have on both pregnancy and infant outcome. In addition, discussion of the evidence base for current management highlights the need for appropriately designed studies to optimise treatment and reduce morbidity.
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