Roster Changes: Please make sure to submit any changes in your team roster. We would like to be able to provide all team members with the latest information about the initiative and we can only do that with your help.
State of the State
Please help PQCNC, and our Partners, by getting your team together to complete and discuss the State of the State survey. Please don't overthink the questions, or your answers, discuss with your team and answer as seems appropriate. Download the survey here - when you have completed the questions click here to record your answers
A multitude of webinars will be available on-demand to assist you in your work
Your team will need to schedule at least monthly meetings to review data, make plans for PDSA cycles, and plan for next steps.
Please set up times to meet with your Executive Champions to update them on your progress and to ask for their help to meet your goals. PQCNC would suggest you meet with them every other month but no less than every quarter.
NC Opioid Dashboard from NCDHHS - Current NC data (follow link, choose Metric Summary Table in left-hand column. Read introductory paragraphs for 2018 data. Orange table represents NC data for 2019)
Perinatal Substance Use Disorders Treatment - North Carolina has been at the forefront of offering treatment for perinatal substance use disorders for over 25 years. Wraparound services, understanding of the fourth trimester, the importance of medication-assisted treatment, and learning from past false predictions regarding illicit prenatal exposure contribute to a nurturing, supportive approach for the mother, child, and families.
The United States opioid epidemic - Addressing this epidemic requires addressing the stigma associated with opi- oid use disorders and its treatment, improving access to efficacious treatment options, specifically methadone and buprenorphine, and reducing opioid overdose fatalities with distribution of the opioid antagonist and overdose reversal agent naloxone
A Public Health Response to Opioid Use in Pregnancy - Several state governments responded to this increase by prosecuting and incarcerating pregnant women with substance use disorders; however, this approach has no proven benefits for maternal or infant health and may lead to avoidance of prenatal care and a decreased willingness to engage in substance use disorder treatment programs. A public health response, rather than a punitive approach to the opioid epidemic and substance use during pregnancy, is critical
Opioid use disorder in pregnancy - Many factors affect opioid use disorder treatment choices during pregnancy; however, when a pregnant person is medically eligible for a therapy and multiple options are available locally, the ultimate decision regarding treatment selection should be left up to the patient and strong support services provided. This approach to treatment results in optimal maternal and neonatal outcomes and long-term maternal engagement and retention in care.
Treatments for opioid use disorder among pregnant and reproductive-aged women - Treatment for opioid use disorder falls into four overlapping do- mains: medication management, medical care, behavioral/mental health care, and psychosocial support. This review discusses these domains with an emphasis on pregnant women and women of reproductive age. Treatment for opioid use disorder is most effective when all providers coordinate care in an informed, nonjudgmental, patient-centered approach.
Models of care for opioid dependent pregnant women - A care model that integrates prenatal care, medication assisted treatment and behavioral health services delivered in a trauma-informed environment can improve prenatal care attendance and thus have far-reaching positive implications for both the woman and her newborn child.
Perioperative pain management strategies among women having reproductive surgeries - This review presents opioid-sparing strategies for perioperative pain management among women undergoing reproductive surgeries and procedures. Recommendations are provided regarding the use of nonsteroidal anti-inflammatory drugs, acetaminophen, other adjunctive medications, and regional anesthetic blocks. Additional considerations for chronic opioid users or patients using opioid replacement or antagonist therapy are discussed.
Stop Talking ‘Dirty’: Clinicians, Language, and Quality of Care for the Leading Cause of Preventable Death in the United States - Use of the more medically and scientifically accurate “substance use disorder” terminology is linked to a public health approach that captures the medical malfunction inherent in addiction. Use of this term may decrease stigma and increase help-seeking. In contrast, tough, punitive, language, including the word “war,” in “war on drugs,” is intended to send an uncompromising message, “You use, you lose,” in the hopes of deterring drug involvement. Accompanying this aggressive rhetoric are terms such as drug “abuse” and drug “abusers,” implying willful misconduct (ie, “they can help it and it is their fault”). This language increases stigma and reduces help-seeking.
Opioid use and stigma: The role of gender, language and precipitating events - results indicated that there were higher stigmatizing attitudes overall towards a male, an in- dividual labeled as a “drug addict” and an individual who took prescription opioids from a friend. Interaction effects also showed that a female labeled with an “opioid use disorder” and male labeled as a “drug addict” were rated with higher stigma. The findings from our study are the first to show that information about gender, precipitating events and language matter when assessing stigma and opioid use and may affect the delivery of patient care.
NAS General: The following articles are from national Groups and organizations as well as background articles.
Neonatal abstinence syndrome - examines the history, incidence and pathophysiology of NAS as diagnostic screening approaches, scoring tools, differing management approaches and recommendations for continued work to improve the care of infants with NAS.
Neonatal Drug Withdrawal: AAP’s statement on neonatal drug 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.
Prenatal Substance Abuse Short- and Long-term Effects on the Exposed Fetus: AAP Committee on Substance Abuse and Committee on Fetus and Newborn report on the most common drugs involved in prenatal exposure, addresses primary care pediatrician’s role in prenatal exposure includes prevention, identification of exposure, recognition of medical issues, protection of the infant and follow-up of the exposed infant.
Neonatal abstinence syndrome: A review that discusses the complex nature of maternal and other factors that can affect the infant’s display of neonatal abstinence syndrome (NAS), clinical presentation and treatment of NAS, and the impact of recent findings on future directions for research.
NICU Nurses’ Lived Experience: primary aim of this qualitative methods study was to describe the lived experiences of neonatal intensive care unit (NICU) nurses with ethical and morally challenging issues.
PQCNC NAS Swimlane: High-level process map indicating the steps in the identification, evaluation, treatment, and discharge of a patient. Pages 1-4 look at the individual process of each area. Page 5 shows the entire process
NAS Identification: The following articles are related to methods for identification of exposure
Opioid Detection in Maternal and Neonatal Hair and Meconium: Characterization of an At-Risk Population and Implications to Fetal Toxicology: Identification of maternal opioid abuse in pregnancy is often difficult to ascertain in the absence of a reliable self-report. This study aimed to characterize an at-risk neonatal population for opioid exposures as well as other drugs of abuse and alcohol
Drugs of abuse testing in meconium: In spite of increased sample preparation time relative to blood and urine, the long metabolic history, coupled with the ease and wide window of collection of meconium make it the ideal matrix for determining fetal drug exposure.
Neo Methods for Neonatal Drug Screening: Article that describes perinatal and neonatal complications of maternal use of cocaine, alcohol, opiates, and barbiturates in pregnancy. Provides established cutoffs of conventional immunoassays of urine for common substances of abuse. List the advantages of using meconium testing for substances of abuse. Describes the role of fatty acid ethyl esters in detecting prenatal alcohol exposure.
Prenatal Substance Exposure: Maternal Screening and Neonatal Identification and Management: Article that describes physical and neurobehavioral problems of neonates who were exposed to maternal substances of abuse. Delineates the purpose of universal screening. Characterizes the areas of inquiry represented by the 4P’s Plus assessment. Describes the significant features of neonatal abstinence syndrome. Delineates supportive measures for management of infants exposed prenatally to substances of abuse
Testing for fetal exposure to illicit drugs using umbilical cord tissue vs meconium: Study with the objective of assessing the agreement of testing for exposure contrasting specimens of meconium vs umbilical cord tissue. Umbilical cord tissue performs as well as meconium in assessing fetal drug exposure to amphetamines, opiates, cocaine, and cannabinoids. Results of studies using the cord may have a more rapid return to the clinician.
NAS Evaluation: The following articles are related to methods to evaluate for NAS
The Opioid Exposed Newborn: Assessment and Pharmacologic Management: Review from the NIH to provide health care professionals with current evidence and practical guidelines for optimal evaluation and pharmacologic management of opioid exposed newborns.
Finnegan neonatal abstinence scoring system: normal values for the first 3 days and weeks 5-6 in non-addicted infants: The purpose of this study was to assess the variability of the scores in newborns and infants not exposed to opiates during the first 3 days of life and during 3 consecutive days in weeks 5 or 6.
Managing Abstinence in Newborns - In 2003, an alternative model of care for infants at risk of developing NAS was established at a large academic medical center in up- state SC. This case report describes the multidisciplinary, coordinated- care model, titled Managing Abstinence in Newborns (MAiN), and lessons learned from 15 years of MAiN development and implementation efforts.
ABM Clinical Protocol #21: Guidelines for Breastfeeding and the Drug-Dependent Woman: Purpose of this protocol is to provide evidence-based guidelines for the evaluation and management of the drug-dependent woman choosing to breastfeed
Methadone Maintenance and Breastfeeding in the Neonatal Period: This study-evaluated concentrations of methadone in breast milk among breastfeeding women and concentrations of methadone in maternal and infant plasma in both groups. Results contribute to the recommendation of breastfeeding for methadone-maintained women
Neonatal Abstinence Syndrome: Therapeutic Interventions: This article provides an overview of the possible risks, benefits, and outcomes of pharmacologic and complementary therapies in the neonatal population, and illustrates the gaps in knowledge related to their use for neonatal withdrawal.
The Opioid Dependent Mother and Newborn Dyad: Nonpharmacologic Care: The purpose of this article is to review the contribution of maternal opioid dependency to the difficulties experienced by the mother-infant dyad and their treatment providers in the postnatal period, and the nonpharmacologic treatment of the infants with suggestions for practical measures with emphasis on the treatment of the mother and baby as an interactional dyad.
Management of neonatal abstinence syndrome: a national survey and review of practice: Aim was To ascertain the present management of neonatal abstinence syndrome (NAS) in neonatal units in the United Kingdom (UK) and Ireland
Neonatal abstinence syndrome: transitioning methadone-treated infants from an inpatient to an outpatient setting: The objective of this study is to compare the safety and efficacy of a traditional inpatient only approach with a combined inpatient and outpatient methadone treatment program
On March 3, 2020 at the RPC Learning Sessio we discussed the intricacies of fetal monitoring - how we utilize it, how we interpret it and how we can improve that process. Teams had the opportunity to network with members from hospitals of similar sizes to discuss strategies and resources to enhance the fetal monitoring process.