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Better coordination of care helps drug-exposed newborns weather withdrawal

Kalamazoo, Mich., May 28, 2015 – As opioid use has spiked across the country, so has its impact on the littlest ones affected: babies exposed in the womb who are born experiencing withdrawal symptoms. The Kalamazoo County NAS Prevention and Treatment Project –– a collaboration of medical professionals, local government and community service providers –– is creating a model for how to potentially improve outcomes for these vulnerable infants and their mothers.

Neonatal Abstinence Syndrome (NAS) describes the withdrawal process newborns endure after being exposed in the womb to opioids — a class of drugs also known as narcotics. Heroin belongs to this class of drugs, as well as frequently prescribed medicines for pain management, such as morphine, hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), codeine and related drugs.

Miseries of NAS range from tremors, excessive crying, sleep problems, high-pitched crying, tight muscle tone and hyperactive reflexes to seizures, poor feeding and sucking, vomiting, diarrhea, dehydration, sweating and fever. Many babies have withdrawal that’s severe enough to receive morphine or methadone to ease the detox process, though how to best treat these infants remains a subject of ongoing debate and research. Weaning off of the treatment medications can require days or weeks in the Neonatal Intensive Care Unit, where anxious parents and nurses cuddle distraught infants for hours at a time.

“To adequately care for any infant with NAS, we can’t just treat the baby,” says Robin Pierucci, MD, a Bronson Methodist Hospital neonatologist. “This problem is way bigger than just what happens in the NICU. It’s too big for one discipline to solve.” Community players include the medical caregivers treating the baby, plus social workers, mental health specialists, the court system, substance abuse treatment centers, early childhood education professionals and more.

Today, thanks to the Kalamazoo County NAS Prevention and Treatment Project, those entities are working together more effectively to create and connect to needed services, like a universal screening tool for early intervention. The project also has changed how babies at risk for or diagnosed with NAS are identified, managed after birth and then connected with resources. This groundbreaking work has put Kalamazoo County at the leading edge among those attempting to handle the multiple ramifications of NAS. “We’re already doing a number of things here in our little community that other places across the nation are just starting to try to do,” Pierucci says. “It’s challenging and exciting.”

Launched in 2012, the project was funded by a grant from The Learning Network of Greater Kalamazoo, with support from the W.K. Kellogg Foundation and Kalamazoo Community Mental Health and Substance Abuse Services.

With its commitment to lifelong learning as a path to success for all Kalamazoo County citizens, it made sense for The Learning Network to invest in improving NAS outcomes, says network director Amy Slancik. “Health and education have been called two sides of the same coin — you can’t embrace education if you are unwell,” Slancik notes. “The Neonatal Abstinence Syndrome project addresses both infant and maternal health issues within one initiative. Just as significant, we were one of dozens of partners at the table, making this a communitywide project and increasing its chances for long-term sustainability.”

Participants (see full list below) include area hospitals, pediatricians, neonatologists, newborn hospitalists, psychiatric providers, obstetrics/perinatology specialists, social workers, toxicologists, the Kalamazoo County Department of Human Services, the local court system, nonprofit community services and Victory Clinical Services methadone program.

The incidence of NAS has nearly doubled from 2009-2012, according to a recent Vanderbilt University study. In Kalamazoo County, one Neonatal Intensive Care Unit saw more than 20 cases in 2013 alone. That doesn’t include NAS cases outside the NICU, undiagnosed cases or those at other facilities.

The growth in NAS cases isn’t surprising. Data from the National Ambulatory Medical Care Survey shows a 73% increase in opioid prescriptions for chronic pain from 2000 to 2010. Opioid use started rising at approximately the same time that the Joint Commission on Accreditation of Healthcare Organizations published guidelines stating that all patients should be asked at every doctor appointment if they are in pain, Pierucci explains. “This made pain a sort of ‘fifth vital sign.’ With increased surveillance of pain has come increased treatment of pain. The unfortunate ripple effect of the increased use of these medications is a parallel increase in babies exposed to opiates in the womb.”

But don’t be too quick to condemn the mother, Pierucci cautions. “It’s so easy to blame the mom when you see this innocent child shrieking from going through withdrawal, but the last thing she wanted to do was intentionally harm her baby. By the time you’re addicted, you’re not intentionally doing this to your baby; you’re just trying to survive,” she says. And not all women who expose their babies are addicted. Studies have found that found that 65% of infants with NAS were exposed to legally obtained opioids. The mothers may be taking prescribed medication before realizing they’re pregnant, or they may not know their painkiller is an opioid that could harm their baby.

“We need to stop blaming and work together. We need a cultural overhaul in how we treat these people,” Pierucci says. Opioid abuse cuts across every economic status. “Whether they got hooked on their painkillers after a car accident or someone just offered them something to try, who knows? It could be any of us.”

Dianne Shaffer, program manager of services for youth and families at Kalamazoo Community Mental Health & Substance Abuse Services, stewarded the NAS initiative for The Learning Network. She says the project’s success is centered on “the relationships built between organizations and service providers – relationships that either didn’t exist before the project or that increased or improved during the project.” People were invested, she says, “because they care about these infants and families and want to be able to do their best to serve them.”

Syncing so many different organizations was a challenge. “Many of the reforms to improve service coordination needed to happen within large organizations that aren’t very nimble and have significant layers of bureaucracy,” Shaffer says. “We were trying to break down silos,” Pierucci adds. “There were a lot of people working on different pieces of this, like teen pregnancy and other issues, but we didn’t know who they were or didn’t have relationships with them.”

Before the initiative, a baby discharged from the NICU might end up seeing a pediatrician who didn’t know the child had NAS. Now protocols have been created to try to ensure that everyone who interacts with the babies and moms knows what each provider is doing, the steps to be taken in treatment and what community resources are available. “It is so amazing to watch the numbers of different groups that are truly coming together. In the community piece, we’re far ahead of some of the other places,” Pierucci says.

Results of this cooperation include simplified referrals, so what used to take a month now takes only a phone call. In free community training sessions, over 100 medical and childcare personnel have learned how to recognize and address potential NAS cases. Mothers now have a “Baby Behavior Booklet” to explain what their infant is experiencing and how to help soothe symptoms. Pediatricians have a one-page checklist for care coordination that outlines how to access available services. Plus, data collection is in place for tracking.

“There’s been some early success in getting these babies off all their meds more quickly than we had before,” Pierucci notes. But completing detox isn’t the end of the problem. It’s too early in the research stage to know exactly how opioids affect the brain in utero, but Pierucci suspects some serious neurological rewiring may be taking place. “We have to follow these kids. The period from age zero to 3 is when the brain is the most plastic it will ever be. So we’re hoping to be able to make an impact by getting these babies hooked up more consistently with groups like Early On and occupational or physical therapy.”

This spring, the project is kicking off a public education effort encouraging pregnant women to tell their doctor about any medications or prescriptions they use. The campaign also reminds women there’s no “safe” level of alcohol or smoking when pregnant.

For women who hesitate to admit opioid use out of fear that Child Protective Services or law enforcement will be called in, Pierucci offers reassurance. “Yes, legally we do have to let them know if a baby is withdrawing and there are drugs in the baby’s system. But it doesn’t mean we automatically take the baby away anymore, because now we’re working with CPS and with family courts. The best way to keep your baby is let us help you get involved in a treatment program.”

While formal funding of the NAS project ends June 30, Shaffer says some members have agreed to come together regularly to discuss data and barriers and do some continued problem-solving.

Considering the scope of the NAS problem, “it’s easy to despair over ever making any difference,” Pierucci says. “The problem can seem too big and too awful. But it takes a lot more courage to maintain hope than to give up, and our community’s collective response has helped strengthen that resolve.”

Partners in the Kalamazoo County NAS Prevention and Treatment Project:

  • Borgess Medical Center
  • Borgess ProMed Pediatrics
  • Borgess Women’s Health
  • Bronson Healthcare
  • Bronson Rambling Road Pediatrics
  • Bronson Women’s Services
  • Catholic Charities
  • Children’s Trauma Assessment Center
  • Community Healing Centers
  • Family Health Center
  • Kalamazoo Community Mental Health & Substance Abuse Services
  • Kalamazoo County Department of Human Services
  • Kalamazoo County Health and Community Services
  • Kalamazoo Regional Education Service Agency
  • Parent to Parent
  • Prevention Works
  • Victory Clinic
  • Western Michigan University Homer Stryker M.D. School of Medicine

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