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Criteria for referral CFS/CPS referral is indicated if birth parent substance use AND unmitigated, significant risk to infant Examples of risk to infant Concerns about birth parents protective capacity for baby Birth parent characteristics associated with active substance abuse Acute mental status changes or changed level of consciousness not otherwise explained Unexplained disorientation, psychosis, manic symptoms, ataxia, hallucinations, internal preoccupation, severe psychomotor agitation, confusion, and or somnolence Concerns about ongoing domestic violence Psychiatric evaluation of birth parent indicating decreased capacity Open CPS case on another child May not be known to providers, can call current case worker to check Prior CPS cases that are closed but risk not mitigated/risk ongoing would promote new CPS referral Evidence of maternal drug use in hospital Should also prompt further needs assessment If birth parent is in foster care, CPS must be notified of birth + Homelessness Other social / safety concerns per usual institutional protocols Each institution is encouraged to develop relationship/lines of communication with local CFS/CPS to discuss best practices Referrals to other services Public Health Nursing (if available in county) Early Intervention Services Refer all drug-exposed infants (Prenatal substance exposure, positive infant neonatal toxicology screen or symptomatic neonatal toxicity or withdrawal) to early intervention programs if qualifying comorbidities Establish Medical Home prior to discharge Clear communication of ongoing needs of infant and family Appendix 1 Characteristics of Various Substances Causing Neonatal Abstinence Syndrome (NAS) Drug Onset, h Frequency, % Half life Duration, d Opioids Heroin 24-48 40-80 Short 8-10 Methadone 48-72 13-94 Long Up to 30 or more Buprenorphine 36-60 22-67 Long Up to 28 or more Other prescription opioid medications 36-72 5-20 Depends 10-30 Nonopioids SSRIs 24-48 20-30 Long (range 20h-4 days) 2-6 TCAs 24-48 20-50 Depends (most ~24h) 2-6 Methamphetamines 24 2-49 Short 7-10 Inhalants 24-48 48 Short 2-7 Onset, frequency and duration of withdrawal in infants exposed to various substances with addition of general half-life of substance

Smoking is now prohibited in most public spaces

Just as sage or palo santo might be used to smudge and clear a space, Amazonian shamans use Mapacho smoke to purify people and places