The Unaware Narcotic Addict: Neonatal Abstinence Syndrome

AUGUST 10, 2015
The significant increase in both illicit and prescription opiate use is a topic we read about almost daily. What we don't read about are the neonates who unknowingly participate in their mothers' narcotic intake.
 
Neonatal abstinence syndrome (NAS) is a condition in which a newborn immediately displays drug withdrawal symptoms upon birth. Infants born with NAS are more likely to need treatment for feeding difficulties, vomiting, diarrhea, seizures, and potential respiratory complications.

The percentage of infants admitted to Neonatal Intensive Care Units (NICUs) for NAS treatment increased from 0.6% of all NICU admissions in 2004 to 4% in 2013, according to a recent study published in the New England Journal of Medicine.
 
NICU admissions for NAS also increased nearly 4-fold from 7 cases per 1000 admissions in 2004 to 27 cases per 1000 admissions in 2013. It was estimated that more than 20% of all NICU days in 2013 were attributed to the treatment of NAS infants.
 
In another recent study, researchers at Vanderbilt University questioned whether the recent increase in NAS cases paralleled with the increase in opiate use over the past few years. The results of this study, which were published in the Journal of Perinatology, found that the increase in NAS cases mirrors the increase in opiate-related issues such as overdose and death.
 
After reviewing the incidence of NAS between 2009 and 2012, these researchers reported that national health care dollars spent on the treatment of NAS nearly doubled from $731 million to $1.5 billion in those 4 years. This increase in health care expenditures correlates with a similar increase in the number of babies born with NAS.
 
Pharmacists have an important role to play in ensuring that the medications used for treatment of NAS are dosed, compounded, measured, and administered appropriately.

The facility where I work uses morphine in a concentration of 0.4 mg/mL as the standard for neonatal NAS withdrawal treatment, but other facilities may use different opiates or concentrations. The neonatologists have agreed on a standard concentration of this medication in order to maintain consistency in the ordering process.
 
In our outpatient pharmacy, we fill 3 or 4 of these prescriptions in any given week. Our technicians have been trained to always show the hard copy prescription to the pharmacist before the patient leaves the store, in order to ensure that there are no complications concerning how the prescription was written.
 
When the prescription is processed, the label will always include the mL dose to be administered and the corresponding dose in mg, i.e. 0.75 mL (=0.3 mg). Prior to compounding a prescription, the math is independently verified by 2 pharmacists, or both a pharmacist and a technician. The label is also verified against the prescription in the same manner. The independent verification of dosing and compounding math by 2 pharmacy employees is paramount with any neonatal prescription. 
 
When dispensing the medication, we always take time with the caregiver to make sure they understand exactly how to draw up the appropriate dose with an oral dosing syringe. I like to have the caregiver teach this back to me by showing the exact dosing calibration on the syringe.
 
If you are unfamiliar with these prescriptions and receive 1 in your pharmacy, please take a moment to call the hospital where the baby was born and speak to the pharmacist on duty. Specifically, it is reasonable to verify the concentration of the opiate being ordered, as well as the compounding technique. A decimal point change could mean life or death.

Steve Leuck, PharmD
Steve Leuck, PharmD
Steve Leuck, PharmD, has been practicing both hospital and community pharmacy for over 30 years. He founded AudibleRx, in 2011, which provides Consumer Medication Information which is both Useful and Accessible. Content designed to meet health literacy guidelines. Format designed to "read along" with the audio presentation in a simple to use web application. More information at AudibleRx.org.
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