SUBSTANCE ABUSE & NEONATAL ABSTINENCE - PowerPoint Presentation

Slide1

SUBSTANCE ABUSE&NEONATAL ABSTINENCE (WITHDRAWAL) Dr reza saeidiassociate professor of neonatology Mashhad university of medical sciences 1393

In The Name of Allah

Slide2

The term opioid refers to natural and synthetic substances with morphine-like activities which activate μ-opioid receptors in the central nervous system. Opiate refers to a subclass of opioids consisting of alkaloid compounds extracted from opium that include morphine, codeine, and semisynthetic derivatives such as heroin, methadone, fentanyl, hydromorphone, and buprenorphineOPIOIDS

Slide3

serious problem for mother and newborn Pregnancy is high riskPrenatal care is inadequatehigher incidence of syphilis, HIV, and hepatitisSubstance abuse during pregnancy

Slide4

risk of preterm labor,IUGR & PROM, perinatal morbidity and mortality is higher.Physiologic addiction in most infants born

Slide5

Withdrawal may be manifested even before birthby increased activity of the fetus

Slide6

acute withdrawal shortly after birth, long-term effects on; physical growth and neurodevelopmentEffects on the fetus and newborn

Slide7

most widely used addictive substance According to the 2007 National Survey on Drug Use and Health(NSDUH), an estimated 70.9 million Americans, 28.6% of thepopulation, reported past-month tobacco use nicotine is theprimary psychoactive chemical responsible for its addictiveproperties. Nicotine is rapidly absorbed through the lungs,permeating the brain within seconds of inhalation; it is absorbed more slowly through oral mucosa and skin.Nicotine binds to nicotinic acetylcholine receptors in the brain, stimulatingthe release of multiple neurotransmitters includingacetylcholine, norepinephrine, -y-aminobutyric acid (GABA),and glutamate. nicotine directly stimulates

dopamine release

in the

mesolimbic

dopaminergic

pathway, or the reward center, and may indirectly sustain dopamine

levels in this region through actions on GABA and

glutamate-containing cells. 107

TOBACCO

Slide8

Nicotine also acts in the periphery, stimulating release of epinephrine from the adrenal cortex, increased heart rate, blood pressure, and respiration. It also suppresses insulin release, which may produce hyperglycemia and affect appetite.Tobacco is highly addictive. Regular tobacco use produces tolerance as well as\ withdrawal symptoms, including irritability,headache, nausea, and craving. Tobacco remains theleading cause of preventable premature death in adults, dueto cancer, chronic respiratory diseases, and cardiovasculardisease, including stroke, heart attack, and certain aneurysms.

Slide9

a health hazard in infants, children, and adults.According to the 2004 Surgeon General's report, tobacco smoking is the cause of 440,000 deaths annually, with health care costs reaching $75 billionPassive exposure to tobacco smoke

Slide10

In 1992, the National Pregnancy and Health Survey performed by the National Institute on Drug Abuse (NIDA) estimated the prevalence of prenatal tobacco use to be 20.4%.In the 2007 NSDUH, 16.4% of women during pregnancy\It has been well established, however, that self-report data underestimate

Slide11

most frequently associated with withdrawal syndromes,such syndromes also occur with; alcohol, phenobarbital, pentazocine, codeine, propoxyphene, hydroxyzine, amphetamines, neuroleptics, antidepressants, and benzodiazepines.Heroin and methadone

Slide12

results in a 50% incidence of LBW half of whom are SGA stillbirths but not congenital anomalies Heroin addiction

Slide13

withdrawal occur in 50-75% Beginning ; 1st 48 hr depending on the daily maternal dose (<6 mg/24 hr is associated with no or mild symptoms) (>1 yr has a >70% incidence of withdrawal) (the incidence is higher if the last dose was taken within 24 hr of birth) Rarely, symptoms may appear as late as 4-6 wk of age Clinical manifestations

Slide14

Slide15

hyaline membrane disease Hyperbilirubinemia accelerated production of pulmonary surfactant may explain the former, and enzyme induction of hepatic glucuronyl transferase

Slide16

Tremors and hyperirritability are the most prominent symptoms. The tremors may be fine or jittery the limbs are frequently rigid, hyperreflexic, and resistant to flexion and extensionIrritability and hyperactivitywakefulness, hyperacusis, hypertonicity, tachypnea, diarrhea, vomiting, high-pitched cry, fist sucking,

Slide17

poor feeding with weight loss (disorganized sucking), and fever Sneezing, yawning, hiccups, myoclonic jerks, convulsions, abnormal sleep cycles, nasal stuffiness, apnea, flushing alternating rapidly with pallor, and lacrimation The risk of SIDS

Slide18

history clinical findings Examining the urine for opiates may reveal only low levels during withdrawal, but quinine, which is often mixed with heroin, may be present in higher concentrationsMeconium testing is more accurate than neonatal urine drug testing. Hypoglycemia & hypocalcemia should be excluded.Diagnosis

Slide19

severe withdrawal the incidence 20-90%mothers; better prenatal care than heroinBut these mothers have polysubstance abuse,congenital anomalies is not increasedaverage birthweight of infants is higher the clinical manifestations are similar

heroin except

:

higher

incidence of

seizures (10-20%)

and

the

late onset (2-6 wk

of age) of symptoms and signs.

Methadone addiction

Slide20

is uncommon- 1-2 infants/1,000 live birthsit rapidly crosses the placenta and blood levels in the infant are similar to those in the motherHypoglycemia and acidosis withdrawal symptoms; agitation and hyperactivity, with marked tremors lasting 72 hr, followed by about 48 hr of lethargy before return to normal activity. Seizures may develop.Alcohol withdrawal

Slide21

alterations in growth and morphogenesis of the fetusHigh levels of alcohol can be damaging to embryonic and fetal development. 32% of infants born to heavy drinkers had congenital anomalies/ 9% in the abstinent / 14% in the moderate group. Additional risk factors ; maternal age, low socioeconomic status, poor psychologic indicators  Fetal Alcohol Syndrome A specific pattern of malformation

Slide22

(1) growth deficiency for length, weight, and head circumference;(2) facial abnormalities, including short palpebral fissures, epicanthal folds, maxillary hypoplasia, micrognathia, and a thin upper lip;(3) cardiac defects, primarily septal defects;(4) minor joint and limb abnormalities, including some restriction of movement and altered palmar crease patterns;(5) delayed development from borderline to severeFetal alcohol syndrome is a common identifiable cause of mental retardation. Characteristics of fetal alcohol syndrome

Slide23

usually occurs in full-term, AGA infants of addicted mothersSymptoms begin at a median age of. 7 d. (2-14 days)irritability, constant crying, sleeplessness, hiccups, and mouthing movements,followed by a subacute stage consisting of voracious appetite, frequent regurgitation and gagging, episodic irritability, hyperacusis, sweating, and a disturbed sleep pattern, all of which may last 2-4 mo.

 

Phenobarbital withdrawal

Slide24

in pregnant women is common, but withdrawal in their infants is unusual;premature labor, abruptio placentae, and fetal asphyxia &IUGRneurobehavioral deficits impaired auditory information processing, developmental delay,

learning disabilities

At 24 mo

, mental scale of the

Bayley

score and are twice as likely to have developmental delay.

Family disorganization,

polysubstance

abuse, sexually transmitted diseases, and child abuse and neglect may also affect these unfortunate families.  

Cocaine abuse

Slide25

Not all infants require drug therapy 1. quiet environment 2. Swaddling3. IV fluids ; prevent aspiration or dehydration The dose and duration of therapy may be adjusted according to the clinical responseTreatment

Slide26

seizures,diarrhea, irritability that normal sleep and feeding patterns are disturbed weight gain is poor Therapy is indicated for

Slide27

Treatment has been successful with various combinations of narcotics, sedatives, and hypnotics. Methadone withdrawal may require larger amounts of medication for longer periods than heroin withdrawal.

Slide28

Phenobarbital, 5-10 mg/kg/24 hr in three to four divided doses, can effectively reduce irritability and prevent seizures. Paregoric at a beginning dose of 0.05-0.1 mL/kg is given every 3-4 hr and increased by 0.05 mL every 4 hr if necessary, Paregoric abolishes most withdrawal symptoms, especially diarrhea. Tincture of opium (10 mg/mL) diluted 25-fold results in the same morphine equivalency as paregoric. The recommended dose of diluted tincture of opium is 0.1 mL/kg ([ap ]2 drops/kg) with feedings every 4 hr. The dose may be increased by 2 drops every 4 hr if needed.

Slide29

Current mortality from withdrawal is under 5%and may be negligible with early recognition and treatmentThe prognosis for normal development is affected by the adverse circumstances of1- high-risk pregnancy and delivery2- the environment  

Slide30

In the western part of the hemisphere, abuse of amphetaminesand methamphetamines is especially predominant,and many users of amphetamines and methamphetaminesare women of childbearing age. the obstetric and neonatal complications associatedwith prenatal exposure to these substances appear to besimilar to those observed with cocaine. Amphetamine (methylphenylethylamine)is a stimulant of norepinephrine, dopamine,and serotonin release, and the clinical effects have alonger duration of action than cocaine.AMPHETAMINES

Slide31

(also known as meth, speed, ice, and crystal), is the N-methylhomologue of amphetamine. With better blood-brain barrier penetration than amphetamine, methamphetamine has significantly higher CNS stimulant effect and less peripheralnervous system and cardiovascular stimulation. Gestational methamphetamine exposure has been reported to increasethe incidence of miscarriage, prematurity, intrauterine growthrestriction, and placental hemorrhage. Infant feeding and sleep patterns are disturbed, and hypertonia and tremorshave been observedMethamphetamine

Slide32

. Little and colleagues, in a retrospectivemedical record review, showed that infants exposed prenatallyto methamphetamine had significantly lower birthweight,length, and head circumference than unexposedcontrol infants.No congenital anomalies neurobehavioral outcomes, lower arousal, and increased lethargy relative to unexposedcontrols. In one study using MRI, children (ages 3 to 16 years) with a history of prenatal methamphetamine exposure were found to have smaller subcortical volumes that correlated with poorer performance on cognitive tests of visual-motor integration, sustained attention, and verbal and long-term spatial memory. 34

Slide33

or MDMA (3,4-methylenedioxymethamphetamine),has become increasingly popular as a recreational drug sincethe late 1980s. MDMA is an indirect monoaminergic agonistthat stimulates release and inhibits reuptake of serotonin andother neurotransmitters, thus evoking elation and pleasure,accompanied by undesirable effects of hyperactivity and hyperthermia.Subsequent monoaminergic depletion leads to depressionand lethargy. Ecstasy

Slide34

Cardiac arrhythmia, acute renal failure,rhabdomyolysis, disseminated intravascular coagulation, anddeath have been reported in young people using MDMA andengaging in "rave dancing" at crowded clubs. Corroborated byanimal studies, chronic MDMA use by adult humans has beenshown to cause long-term neuropsychopharmacologic damagein terms of learning/memory, cognitive function, sleep, appetite,and loss of sexual pleasure. These effects persist even duringabstinence, suggesting permanent axonal loss.

Slide35

Although not categorized as abuse substances, there is evidencefor increasingly widespread maternal use of selectiveserotonin reuptake inhibitors (SSRIs) during pregnancy.I 63These drugs are being commonly prescribed as the treatmentof choice for major depression and anxiety. AlthoughSSRIs vary in potency, pharmacokinetic effects, molecularstructure, and half-life, the SSRIs act similarly by inhibitingserotonin reuptake at the presynaptic junction, leading toincreased concentrations at the synaptic cleft and potentiatingserotonergic neurotransmission. SEROTONIN REUPTAKE INHIBITORS

Slide36

Thus, the fetus is exposed to increased serotonin levels during development.An early meta-analysis of several smaller studies of SSRIuse in the first trimester was reassuring with regard to nodemonstrable increased risk for congenital malformations,93 but subsequently concerns have been raised regardingan observed increase in congenital malformations associatedwith maternal therapy during pregnancy withSSRIs, especially paroxetine (Paxil). 23 Gestational SSRI exposurehas also been implicated in persistent pulmonaryhypertension of the newborn, but this observation also requiresfurther substantiation. There is an emerging literaturethat prenatal SSRI exposure and possibly withdrawalmay be associated with neurobehavioral effects that mayinclude changes in behavioral state and altered autonomicreactivity. Whether this actually constitutes a neonatal abstinencesyndrome and whether there are long-term developmentalconsequences of in utero exposure to SSRIs remainsunclear. Awaiting more definitive long-term studiesof safety, clinicians should carefully consider the maternal

diagnosis and indications as well as the potential risks and

benefits before prescribing treatment with SSRIs during

pregnancy.

Slide37

Thank you For your attention