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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