Research Article Critique Assignment

Research Article Critique Assignment

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Research Article Critique Assignment

49SubStance abuSe: ReSeaRch and tReatment 2016:10(S1)

Introduction The incidence of neonatal abstinence syndrome (NAS) secondary to opioid withdrawal is more than 4 cases per 1000 deliveries in Canada and the US.1 This translates to an esti- mated 3%–4% of NICU beds at any given time being utilized for these infants, leading to increased health care expenditures due to prolonged hospital admissions for the management of NAS.4,5

Since the inception of neonatal abstinence tools, there has been a growing evolution toward embracing, where pos- sible, a consensus in the care of newborns with opioid with- drawal. Most, if not all, opioid-exposed infants experience NAS to some degree,6 which occurs with notable heteroge- neity.2,7,8 Furthermore, NAS severity has not been related to maternal methadone dose or cumulative methadone exposure in utero.9 Most NAS management recommendations suggest that nonpharmacologic therapy should be the standard of care for all opioid-exposed infants.3,10–12 For a subset of infants

with NAS, nonpharmacologic therapy alone is insufficient to prevent significant morbidity, and institution of appropriate pharmacologic management is indicated.3,13,14 Most pharma- cologic treatment strategies include the use and gradual wean- ing of a single opioid.10,12,15,16

There are two different strategies for evaluation and treatment of NAS: a weight-based scale, in which medication is dispensed on a milligram per kilogram basis, and a symptom-based scale, in which medication dose is determined by NAS score.13 These two regimens vary in terms of the recommended initial dose, dose increments, weaning dose, and initiation of adjunctive treatment (Table 1). No standardized approach has been determined due to lack of comparative studies. Furthermore, there are limited stud- ies providing evidence for morphine doses used in either model. On comparing discharge strategies, the accumulative morphine dose of inpatient and combined in- and outpatient models has been described to be around 3.2–3.6 mg/kg/day. Daily doses of morphine ranged from 0.24 to 1.3 mg/kg/day.17,24

A Comparison of Morphine Delivery in Neonatal Opioid Withdrawal

brian chisamore1, Safaa Labana1, Sandra blitz2 and alice Ordean3 1Department of Paediatrics, St. Joseph’s Health Centre, Toronto, Canada. 2University Health Network, Toronto, Canada. 3Department of Family and Community Medicine, St. Joseph’s Health Centre, Toronto, Canada.

Supplementary Issue: Substance Use in Pregnancy

Abstr Act: Current estimates of the prevalence of opioid withdrawal in newborns from the 2012 Better Outcomes Registry and Network Ontario reveal that more than 4 births per 1000 display recognizable symptoms of neonatal abstinence syndrome (NAS). With a growing consensus surrounding aspects of newborn opioid withdrawal care, clinicians might agree that all infants exposed to maternal opioids require supportive observation and care to ensure appropriate adaptation and growth in the newborn period and, likewise, that there exists a smaller percentage of newborns who require additional pharma- cotherapy. However, due to the dearth of comparative studies of NAS tools, there remains a lack of evidence to support the use of a specific NAS method of scoring or treatment. Two types of NAS treatment protocols currently in use include a symptom-only versus weight-based protocols. Our Neonatal Intensive Care Unit (NICU) has used both models. A formal structured NAS tool and weight-based morphine delivery system began in our NICU in 1999. We audited all newborns with known exposure to maternal opioids in our NICU from the years 2000 to 2014. The Finnegan scoring tool was used throughout all years of the chart audit. Modifications made to the Finnegan scoring tool from the MOTHER study were adapted for use in our NICU at the same time as adopting the Johns Hopkins model of symptom-only based morphine delivery in 2006. The objective of this comparative study using a retrospective chart audit is to compare length of stay (LOS) and total accumulative morphine dose across these two morphine delivery protocols. Our audit revealed that there were a significantly higher proportion of newborns in the symptom-only model that received morphine and, perhaps accordingly, also had a significantly higher LOS compared to those in the weight-based model. Comparing only those infants who did receive morphine, the comparative total accumulative dose of morphine and LOS were not significantly different between the weight-based and symptom-only morphine delivery models.

Key words: neonatal abstinence syndrome, opioid withdrawal, methadone

SUPPLEMENT: Substance use in Pregnancy

CITATION: chisamore et al. a comparison of morphine delivery in neonatal Opioid Withdrawal. Substance Abuse: Research and Treatment 2016:10(S1) 49–54 doi: 10.4137/SaRt.S34550.

TYPE: Original Research

RECEIvED: december 15, 2015. RESUbMITTED: July 31, 2016. ACCEPTED fOR PUbLICATION: august 05, 2016.

ACADEMIC EDITOR: Gregory Stuart, editor in chief

PEER REvIEW: two peer reviewers contributed to the peer review report. Reviewers’ reports totaled 1246 words, excluding any confidential comments to the academic editor.

fUNDINg: authors disclose no external funding sources.

COMPETINg INTERESTS: Authors disclose no potential conflicts of interest.

CORRESPONDENCE: chisab@stjoe.on.ca

COPYRIghT: © the authors, publisher and licensee Libertas academica Limited. this is an open-access article distributed under the terms of the creative commons cc-bY-nc 3.0 License.

Paper subject to independent expert blind peer review. all editorial decisions made by independent academic editor. upon submission manuscript was subject to anti- plagiarism scanning. Prior to publication all authors have given signed confirmation of agreement to article publication and compliance with all applicable ethical and legal requirements, including the accuracy of author and contributor information, disclosure of competing interests and funding sources, compliance with ethical requirements relating to human and animal study participants, and compliance with any copyright requirements of third parties. this journal is a member of the committee on Publication ethics (cOPe).

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Chisamore et al

50 SubStance abuSe: ReSeaRch and tReatment 2016:10(S1)

Since there have been no comparative studies of these two protocols, the objective of this study was to compare NAS outcomes consisting of morphine doses and length of stay (LOS) for the two models of morphine delivery.

A brief history of NAs at st. Joseph’s Health centre. Our hospital developed the Toronto Centre for Substance Use in Pregnancy (T-CUP) in 1997.18 With the growing number of women attending T-CUP with a diagnosis of opioid use disorder, so did the census of newborns with NAS. There were frequent occasions during which infants with opioid withdrawal NAS took up to 25% of our given daily census. As a result, we began using a formal structured NAS tool and weight-based morphine deliv- ery system in our NICU in 1999. The Finnegan scoring tool was used until a modified scoring tool was adapted. As a site for the MOTHER study, the NICU switched to the Johns Hopkins model of symptom-only based morphine delivery13 in 2006.

Our protocol of NAS opioid withdrawal treatment, whether weight based or symptom only, used a monother- apy of morphine sulfate 0.5 mg/mL. Clonidine was used as a co-therapy when the total daily dose of morphine reached 1 mg/kg/day, regardless of morphine delivery model. The pro- tocol did not use barbiturates or benzodiazepines for opioid withdrawal. No infants were discharged from the hospital with prescribed opioid therapy. Infants with known metha- done exposure were observed for a minimum of 120 hours. Discharge occurred from hospital after a minimum of 48 hours after discontinuation of morphine.

In our participation in the MOTHER trial, our NICU group believed that the changes to the Finnegan tool, now renamed the MOTHER NAS scale,12 would result in reduc- tions in the degree of subjectivity needed to measure previ- ously problematic items. Specifically, the MOTHER NAS scale clarified certain items like “tone”, “crying”, and “irrita- bility” that were confusing and subject to inflation by adding objective and concrete descriptions. Further, an experienced rater could modify intermediate scores potentially inflated by “everyday baby crankiness.”

Despite the provincial consensus recommendation to use the Finnegan scoring tool, we remained the only NICU in Ontario using this morphine delivery model. As a result, it became important to discover whether there were differences in how LOS and accumulative morphine were affected by use of these variable morphine delivery systems.

At the onset of the audit, we postulated that the LOS would not be different between the two models. In the symptom-only morphine delivery model, there were babies who would proceed with successful and structured morphine administration and weaning, only to be discharge ready and 48 hours free of mor- phine, well under our usual expected LOS of 2–3 weeks in these babies. However, we speculated that the audit might not demo- nstrate a difference in the total amount of morphine delivered between the two cohorts of morphine delivery models.

A stringent NAS treatment and weaning protocol, rather than the particular opioid chosen for treatment, has been shown to be the most important predictor of length of stay and duration of opioid treatment.10 Our intent of the audit was to shed light only on the choice of morphine treatment and weaning pro- tocols. We postulated that our retrospective chart audit would support that the adoption of a structured model of morphine delivery – be it weight based or symptom-only based, in con- cert with an accepted neonatal scoring tool like the Finnegan – would result in a similar LOS and accumulative morphine dose. We conclude with recommendations reflected by our audit with respect to a chosen morphine delivery model and discuss the resource management decisions resulting from the audit.

Methods All newborns born in our hospital from January 1, 2000, to December 31, 2014, inclusive, and whose chart was coded with an ICD10 of P96.1, were identified. A total of 278 charts were flagged for audit during this time period. Those infants exposed to maternal opioids through confirmed drug screen and or self-admitted use were included in the audit (n = 172). Maternal use of other drugs and antidepressant use during pregnancy were captured by either self-report and/or by posi- tive maternal or infant toxicology testing.

Preterm infants with less than 37 completed weeks of Gestational Age (GA) were excluded (n = 23). Any newborn considered to have a condition whose neurologic status would interfere in a proper assessment of neonatal withdrawal was excluded (ie, pain from birth trauma, lethargy from sepsis [n = 2]). Any newborn, whose care required transfer to another NICU, and therefore whose medication administration records could not be assessed in our hospital audit, was also excluded (n = 1). The total number of newborns’ charts audited was 146. This research was approved by the Research Ethics Board of St Joseph’s Health Centre.

Measurements of primary outcomes. Primary out- comes measured were the length of stay (LOS) and the total (all inhospital) accumulative morphine dose used for each newborn. Information for infants’ LOS was derived from hos- pital discharge face sheets. Two parts of a newborn’s flagged chart were used to obtain the peak NAS score and the total accumulative morphine dose: the baby’s medical administra- tion record and our handwritten NAS scoring records. Each morphine dose from the newborn’s medication administration record was added to create a total accumulated morphine dose.

Table 1. comparison of naS models.

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